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TABLETS & GRANULES
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LACTINEX contains a standardized viable
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LACTINEX was introduced to help
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References: (l) Siver, R. H.: CMD, 21:109, September
1954. (2) Frykman, H. H.: Minn. Med., 38:19-27,
January 1955. (3) McGivney, J.: Tex. State Jour. Med.,
>1:16-18, January 1955. (4) Quehl, T. M.: Jour, of
Florida Acad. Gen. Prac., 13:15-16, October 1965. (5)
Weekes, D. J.: N.Y, State Jour. Med., 38:2672-2673,
August 1958. (6) Weekes, D. J.: EENT Digest,
23:47-59, December 1963. (7) Abbott, P. L.: Jour. Oral
Surg., Anes., & Hosp. Dental Serv., 310-312, July 1961.
(8) Rapoport, L. and Levine, W. I.: Oral Surg., Oral
Med. & Oral Path., 20:591-593, November 1965.
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
Volume XX January, 1967 Number 1
CONTENTS
Clinocopathological Conference — Sioux Valley Hospital 23
John F. Barlow, M.D.; Warren L. Jones, M.D.
Adenoid Cystic Carcinoma of the Middle Ear and Mastoid Cavity
With a Case Report 31
Richard J. Weaver, M.D.; Lothar Kaul, M.D.
Giant Pericardial Cyst with Cardiac Manifestations 41
Thomas J. Yeh,M.D.; Isam N. Anabtawi, M.D.
PathCAPsule 44
Deadwood Doctor 47
Editorials 50
This Is Your Medical Association 53
Second Class Postage Paid at Sioux Falls, South Dakota
Published monthly by the South Dakota Medical Association, Publication Office
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THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
SUBSCRIPTION $2.00 PER YEAR SINGLE COPY 20c
Volume XX
January, 1967
Number 1
STAFF
Editor
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Robert Van Demark, M.D.
Judith Perkins Schlosser
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Gordon Paulson, M.D
Gerald Tracy, M.D
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Sioux Falls,
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EDITORIAL COMMITTEE
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Hugo Andre, M.D 1 Vermillion,
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R. F. Thompson, M.D. Yankton,
John B. Gregg, M.D. sioux FaMS|
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R. H. Quinn, M.D.
E. T. Lietzke, M.D.
J. P. Steele, M.D
Mitchell,
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Marion,
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Beresford,
— Yankton,
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Sioux Valley Medical Association
President C. J. McDonald, M.D
Secretary Daniel Youngblade, M.D.
i reasurer Karl Wegner, M.D
Sioux Falls, S. D.
.Sioux City, Iowa
Sioux Falls, S. D.
CLINICOPATHOLOGICAL CONFERENCE - SIOUX VALLEY HOSPITAL
From the Intern and Resident Teaching Conferences of the Sioux Valley Hospital, Sioux Falls
JOHN F. BARLOW, M.D.* *
Pathologist — Editor
WARREN L. JONES, M.D.**
Internist — Discusser
This 30-year old Caucasian female first be-
came aware of an abnormality of her heart four-
teen months prior to the final admission. At this
time she received a report of a chest x-ray taken
by the State Department of Health six months
previously. Large pulmonary arteries and ques-
tionable cardiovascular disease were described.
She had mild dyspnea and dizziness but no or-
thopnea, paroxysmal nocturnal disease, chest
pain, ankle edema, or history of rheumatic
fever. There was no family history of heart
disease.
On the first visit to the clinic the patient was
a well-developed, well-nourished, somewhat
pale, Caucasian female without noticeable
cyanosis. Blood pressure, pulse, and tempera-
ture were normal. There was a Grade I systolic
murmur and a narrow split of the second sound
with most marked prominence of the pulmonic
component. There were no rales, ankle edema,
or other signs of heart failure. There was no
calf tenderness or swelling. There was no club-
bing of the fingers or toes.
An x-ray showed cardiomegaly which was
first thought to be left ventricular hypertrophy.
However, cardiac fluoroscopy showed the en-
largement was of the right ventricle and all
the other chambers of the heart appeared nor-
mal. The lung fields were clear.
The patient was sent elsewhere for cardiac
catheterization which was done six months
prior to death. Laboratory data revealed a nor-
mal skull x-ray, intravenous pyelogram, electro-
encephalogram, complete blood count, erythro-
cyte sedimentation rate, urinalysis, blood urea
This case is presented through the courtesy of Drs.
Theodore Wrage and Gerald Tracy of the Brown
Clinic in Watertown, South Dakota.
*Lecturer in Pathology, School of Medicine, Univer-
sity of South Dakota.
**Clinical Associate Professor of Medicine and
Assistant Dean for Clinical Affairs, School of Med-
icine, University of South Dakota.
nitrogen, fasting blood sugar, LE clot test,
serum electrolytes, serum proteins, serology,
PSP, and latex fixation. The PBI was 1.3 ug%
(normal 4-8 ug%) and the T3 was 33.8% (normal
24-36%). There were no signs or symptoms of
hypothyroidism or hyperthyroidism. An electro-
cardiogram showed an early right ventricular
hypertrophy pattern. Repeat fluoroscopy tests
showed enlargement of the right ventricle with
marked enlargement of the proximal pulmonary
segment and considerable clearness of the peri-
pheral lung fields. A Papanicolaou smear showed
suspicious cells and subsequent biopsies in-
dicated an invasive squamous cell carcinoma.
The patient was treated with digitoxin and
given 5000 milligram hours of radium + 3115
tissue roentgens of external irradiation to the
pelvis over 20 days. The only complication of
the radiation treatment was leukopenia which
was as low as 2150/Cu3. These counts later re-
turned to normal.
The cardiac catheterization data were in-
terpreted as follows:
1. Markedly elevated total pulmonary and
pulmonary arteriolar resistances with nor-
mal pulmonary wedge pressure.
2. Subnormal cardiac output at rest.
3. Moderate tricuspid insufficiency with right
ventricular failure and a small right to left
shunt via valve competent foramen ovale.
Subsequent to cardiac catheterization the pa-
tient was hospitalized four months prior to the
final admission for a perirectal abscess which
promptly responded to surgical drainage. Two
months prior to admission she was seen because
of early pneumonia in the left lower lobe.
She was seen on the day of final admission in
the emergency room because of severe pain in
the anterior chest which was aggravated by res-
piration and became more severe in the hour or
two just prior to admission. She was not cough-
ing frequently but each cough was extremely
23 —
SOUTH DAKOTA
painful for her. Admission physical revealed
an enlarged heart with rales in the left lower
lobe. The patient was mildly cyanotic and
slightly dyspneic. After admission, the pain be-
came more severe and the patient became in-
tensely cyanotic. An electrocardiogram showed
some changes over the right side of the heart
and some digitalis effect. She was placed in an
oxygen tent. Abnormal laboratory findings in-
cluded a white count of 13,000 with 84% polys,
1+ albuminuria, transaminase of 665 units and
a blood urea nitrogen of 30 mg.%. The cyanosis
and chest pain continued and the liver became
enlarged and tender. On the day following ad-
mission, however, the patient felt somewhat
more comfortable and the transaminase dropped
to 400 units. A bilirubin at that time was 2.9
mg.%, chloride 100 meq/L, CCk combining power
27.3 meq/L, potassium 5.1 meq/L, sodium 131
meq/L. The oxygen was discontinued and she
seemed to be getting on relatively well. How-
ever she was found dead in bed three days after
admission, shortly after having been seen by
visitors.
DR. WARREN L. JONES: The case at hand is
a 30-year old white female who first became
aware of an abnormality of her heart fourteen
months prior to the final admission. Since the
sequence of events in this protocol is a bit con-
fusing, reference to the illustration (Figure #1)
30 TEAKS OF AGE. MILD STUDIED AT UNIVERSITY
SURVEY CHEST SYMPTOMS. UNDERWENT HER MEDICAL CENTER; CARDIAC
X-RAY TAKEN FIRST EXAMINATION RELAT- CATHETERIZATION. LLL PNEUMONIA DEATH
/ ING TO THE LAST ILLNESS. I V
j_<%___6_MONTHS_ / 8 MONTHS _ j 2 MONTHS _ x 2 MONTHS^2_MONTHX 3 DAYpx
T7 ' l
PERI-RECTAL FINAL HOSPITAL
ABSCESS ADMISSION
^ - -J
14 MONTHS
CHARTS THE SEQUENCE OF EVENTS DURING THE LAST ILLNESS
Fig. I
will serve as a guide to the reader. The total
period of time from when this patient was seen
on initial examination to the time of death is
fourteen months, and twenty months from the
time of the survey chest x-ray to the time of
death. I think this time relationship may be
helpful to me in coming to some conclusions.
The patient received a report of her chest x-ray
taken by the State Department of Health six
months previously, and there were reported
large pulmonary arteries and questionable car-
diovascular disease. At that time she had mild
dyspnea and dizziness but no orthopnea, no
paroxysmal nocturnal dyspnea, no chest pain,
ankle edema, or history of rheumatic fever.
There was no family history of heart disease.
At this particular time one might ponder a
bit. It is not unusual to see a person at 30 years
of age with the first knowledge of a cardio-
vascular lesion such as one of the rheumatic
valvular heart lesions, or a congenital lesion
such as an interatrial septal defect or patent
ductus arteriosus, which may not manifest
symptoms until the patient is of this age.
The physical examination at the time of that
clinic visit revealed a well-developed, well-
nourished, somewhat pale white female who
showed no evidence of cyanosis. The fact that
she did not have cyanosis at the time of that
examination will help us in the final diagnosis.
The blood pressure, pulse, and temperature
were normal. There was a Grade I systolic mur-
mur and a narrow split of the second sound
over the base of the heart with most marked
prominence of the pulmonic component (from
the way this was stated, I presume this was
a splitting of P-2, or the pulmonic second sound).
If my presumption is correct this would mean
that the patient had considerable pulmonary
hypertension. The splitting of P-2 is of interest.
This indicates an assynchrony of the closures of
the pulmonic and aortic valves. It is often seen
in the presence of pulmonary hypertension. It
is a point helpful in the diagnosis in the case of
interatrial septal defect in which case the split-
ting of P-2 is usually a fairly wide split along
with a pulmonic systolic blowing murmur. In
the case of pulmonary hypertension for any
reason we may have a splitting of P-2. In pul-
monary hypertension there is, at times, a “click”
sound heard some time during systolic ejection,
which is thought to be related to the height of
the pressure in the pulmonary artery.
Further, on physical examination there were
no rales, no ankle edema, no other signs of heart
failure, no calf tenderness or swelling. There
was no clubbing of the fingers or toes. I
think this is an important point. The absence of
cyanosis and the absence of clubbing means to
us that there was not a congenital cardiovas-
cular lesion with a veno-arterial shunt. Further-
more, if we had a slowly progressing pulmonary
disease she should have had clubbing of the
digits, but there was none. Further, an x-ray
showed cardiomegaly which was first thought
to be left ventricular hypertrophy, but sub-
sequently a cardiac fluoroscopic study was per-
formed which showed enlargement of the right
ventricle and apparently all of the other cham-
bers of the heart were normal. The lung fields
were clear. Dr. McHardy, will you please dis-
cuss the x-rays.
— 24 —
JANUARY 1 967
DR. B. R. McHARDY*: The most striking thing
is the dilatation of the pulmonary artery with
normal or slightly reduced vascularity of the
peripheral lung fields. (See Figure #2). These
findings are characteristic of pulmonic stenosis
with poststenotic dilatation of the pulmonary
artery. The history and physical, however, do
not seem to suggest congenital heart disease.
Fig. II — This chest film was shortly before the pa-
tient’s death and reveals marked dilatation of the pul-
monary artery and clear peripheral lung fields.
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Ji
i
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Cl rj
jyj
wffi
. .. ■
c
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;
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i y
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Li
11
Fig. Ill — Electrocardiogram (see protocol).
DR. JONES: The patient was sent elsewhere for
further studies fourteen months after the orig-
inal chest film and six months before she died.
Laboratory data revealed a normal skull x-ray;
why this was performed I’m not sure. No men-
tal or neurological symptoms were noted in
the protocol. An intravenous pyelogram, elec-
troencephalogram, complete blood count, sed
rate, urinalysis, BUN and fasting blood sugar
were negative as were a number of other tests.
I might point out here that with a normal blood
count I think we can state that the patient did
not have a secondary polycythemia. The PBI
was recorded below the normal range, but the
T-3 was within the normal range. Clinically the
patient showed no evidence of thyroid disorder
so I think that I will dismiss this possibility.
An electrocardiogram showed an early right
ventricular hypertrophy pattern. We have two
electrocardiograms representing the original
examination at the Watertown clinic. One of
these is shown in Figure #3. There is a right
axis deviation, a vertical cardiac position, some
ST and T abnormalities in leads II, III, AVF,
and in the chest leads we have a peculiar pat-
tern which I’ll mention because it could
represent an anteroseptal myocardial infarc-
* Attending Radiologist, Sioux Vabey Hospital.
tion. You will notice in lead V-l an abnormal
Q with high take-off of the ST and a diphasic T.
V-2 is rather similar with a smaller Q, but it is
a broad Q. One cannot help but be just a little
uneasy about this type of configuration in leads
V-l and V-2. Now, in a previous CPC I made
quite an issue of these particular points but
recall in that particular case the ECG showed a
horizontal cardiac position, and a left axis
deviation, whereas in this patient we have sim-
ilar findings which could be considered an ab-
normal Q wave in leads V-l and V-2, with no
abnormal Q waves in any of the limb leads, but
in the presence of a right axis deviation and
vertical position of the heart. This puts a little
bit different light on these particular findings.
In this case I am laying no significance to this
finding, and regard it as a part of the posi-
tional pattern in this electrocardiogram. The
presence of a rather prominent right ventricular
hypertrophy pattern coincides with our clinical
picture up to now.
Fluoroscopic studies of the chest and heart
disclosed enlargement of the right ventricle and
a marked enlargement of the proximal pul-
monary artery segment and considerable clear-
ness of the peripheral lung fields. The reduced
vascular markings in the peripheral lung fields
is a very helpful point for several reasons. If this
— 25 —
SOUTH DAKOTA
patient had an interatrial septal defect or patent
ductus arteriosus, we would expect not a de-
crease of the peripheral lung markings, but ex-
cessive pulmonary vascular markings. In fact,
under the fluoroscope in either of these con-
ditions we usually see large pulsating hilar
shadows which are sometimes referred to as
the “hilar dance.” Obviously we do not have
this particular finding here, and can there-
fore rule out these congenital lesions.
A Pap smear of the cervix was positive for
malignant cells. Cervical biopsies were per-
formed and invasive squamous cell carcinoma
was found. The time relationship between this
relatively early finding, and the rather ad-
vanced pulmonary findings which had already
been manifest for eight months does not co-
incide. Therefore, I cannot directly relate these
pulmonary and cervical findings to the same
disease process. The patient was given x-ray
and radium therapy to the cervix in apparently
the usual doses and method. Evidently she
showed some congestive heart failure at that
time and was digitalized. A leukopenia de-
veloped which one might expect. The WBC
later returned to normal.
A cardiac catheterization study was performed
and the results of this study are outlined in the
protocol. The detailed data, however, give us
no more information than is presented in the
protocol. Several points warrant further dis-
cussion:
(1) There was marked elevation of the total
pulmonary and pulmonary arteriolar resist-
ances, with a normal pulmonary wedge pres-
sure. The normal pulmonary wedge pressure
means that the hypertension is not present in
the capillaries or venous side of the pulmonary
circulation. This rules out left-sided heart
failure as a cause of the pulmonary hyperten-
sion. This would also mean to me that the pul-
monary hypertension does exist above the pul-
monic valve and therefore this could not repre-
sent a case of pulmonic valvular stenosis. (2)
There was reported a subnormal cardiac output
at rest. This point simply means to me that
there was sufficient resistance in the pulmonary
circuit such that blood flow to the left side of
the heart and aorta was diminished. (3) A mod-
erate tricuspid insufficiency with right ven-
tricular failure and a small right to left shunt
via a valve competent foramen oval was found.
I can find no help in arriving at my diagnosis
from these points.
Subsequent to cardiac catheterization the pa-
tient was hospitalized four months prior to final
admission for treatment of a perirectal abscess
as indicated in Figure #1. This is not unexpected
following heavy x-ray therapy. Surgical drain-
age took place. Two months prior to the final
admission she was rehospitalized for treatment
of an early pneumonia involving the left lower
lobe.
On the day of her final hospital admission she
was seen in the emergency room because of
severe pain in the anterior chest which was ag-
gravated by breathing and became more severe
in the hour or two just prior to admission. There
was rather sudden onset of severe symptoms of
pleurisy. When pleurisy is present with acute
bacterial pneumonia the patient is usually
febrile, toxic and ill for 6-8 hours or longer be-
fore pleurisy begins. Since pleurisy was an early
symptom, and taking into account the preceding
events, I’d be most thoughtful of pelvic or fem-
oral phlebothrombosis and embolization with
pulmonary infarction causing these symptoms.
The admission physical examination revealed
an enlarged heart and rales in the left lower
lobe which one might expect with pneumonia or
infarction. The patient was mildly cyanotic
which one might expect under these circum-
stances, whether due to pneumonia or pulmon-
ary infarction. After admission the pain became
more severe and the patient became intensely
cyanotic. An electrocardiogram showed some
change over the right side of the heart and some
digitalis effect. This doesn’t help me very much.
If indeed the patient had had a pulmonary in-
farction we would see intensification of the
already existing right ventricular hypertrophy.
Oxygen therapy was begun. Abnormal labora-
tory findings included an elevated WBC with
some “shift to the left.” There was a 1+ pro-
teinuria. The serum transaminase was high,
which I suppose was the SGOT. One might have
an elevated transaminase level in either acute
pneumonia or pulmonary infarction. The BUN
was somewhat elevated. Cyanosis and chest
pain continued and the liver became enlarged
and tender. This means to me that the patient
was going into an acute right-sided heart fail-
ure, which might occur with either an acute
pneumonia or pulmonary infarction.
The day following admission she felt better
and presumably had the oft-seen “good before
the bad.” The serum bilirubin was elevated
which helps a little bit to differentiate pul-
monary infarction from an acute pneumonia.
I think the elevated bilirubin leans towards a
pulmonary infarction, since greater break-
down of hemoglobin occurs in pulmonary in-
26—
JANUARY 1967
farction overloading the hepatic cells tempor-
arily, whose function is already reduced by the
existing passive congestion. This ought not be
seen in acute pneumonia.
The CO2 combining power was normal, the
potassium was elevated, and the sodium was a
low normal. Oxygen was discontinued be-
cause she was feeling better. After visiting
with relatives she was found unexpectedly
dead. I would say that she probably died
from a second pulmonary embolus from a phle-
bothrombosis, probably originating in the pelvic
veins. I still have not satisfied my thoughts in
regard to the primary phases of this illness. We
have evidence of there being pulmonary hyper-
tension. We have ruled out several congenital
cardiac defects. Rheumatic valvular heart dis-
ease seems unlikely and is ruled out. I am faced
with the frustrating thoughts of how to relate
the pulmonary hypertension to the known in-
vasive carcinoma of the cervix and have
pondered this for some time. I really cannot
relate them. I think this lady probably had two
different diseases or two unrelated disease pro-
cesses. She had an invasive carcinoma of the
cervix, and I think this was probably related to
the development of phlebothrombosis of the
pelvic veins, leading to the final phase of
illness due to pulmonary infarction. In addition
she had pulmonary hypertension, and I’m going
to hazard a guess that she had the unusual idio-
pathic pulmonary arteriosclerosis that occurs in
young women leading to a rapid, relentless course
of illness and death within the length of time
witnessed in this case. Now usually polycy-
themia, cyanosis, and clubbing of the digits are
also present. These helpful findings were not
present in our case. Although I am not satisfied
with this final diagnosis, I have unravelled the
facts stated in the protocol as far as I can.
Perhaps others here would like to further dis-
cuss this case.
DR. JOHN F. BARLOW: Dr. Sanderson, will
you please comment on the electrocardiogram.
DR. E. W. SANDERSON*: The electrocardio-
gram is nonspecific but is compatible with right
ventricular strain or hypertrophy, not particu-
larly an infarct pattern. I don’t have any idea
what is going on in this case. I am suspicious
since two or three people have told me there
was a very unusual demise. I am afraid pulmon-
ary embolus and infarction are too simple an ex-
planation for this patient. I am concerned about
a patent foramen ovale. If there were sig-
nificant interatrial shunting with left to right
^Internist, Sioux Valley Hospital.
shunt, the patient might have developed pul-
monary hypertension. The possibility of right
sided endocarditis superimposed on a septal de-
fect or tricuspid valve should be considered as
well as diffuse vascular spread of a carcinoma
of the cervix.
DR. WARREN L. JONES: Dr. Stahmann, what
do you think about the carcinoma of the cervix?
DR. F. S. STAHMANN**: There is not much to
discuss. This sounds like a routine carcinoma of
the cervix treated in a routine way. I doubt
diffuse spread of the lesion.
DR. WARREN JONES' DIAGNOSES
1. Primary P ulmonary Hypertension
2. Multiple P ulmonary Emboli with Infarction
3. Acute Congestion of Liver
4. Squamous Cell Carcinoma of the Cervix , Treated
PATHOLOGIC DISCUSSION
DR. BARLOW: Upon opening the chest the
pericardium was distended with 850 cc. of liquid
and clotted blood. The source of the tamponade
was a longitudinal rent in the main pulmonary
artery. Sections about the tear revealed or-
ganized fibrous tissue indicating that the tear
had taken place over a period of time rather
Fig. IV — Large rent in pulmonary artery.
than suddenly. There were areas of cystic
medionecrosis of the pulmonary artery media
near the tear. These areas were vividly demon-
strated on elastic tissue stain.
**Obstetrician and Gynecologist, Sioux Valley Hos-
pital.
— 27
SOUTH DAKOTA
In addition the pulmonary artery was hugely
dilated below an organizing thrombus. There
were no other thrombi in the pulmonary ar-
Fig. V — Thrombus in pulmonary artery.
Fig. VI — Cystic changes in wall of pulmonary artery
near rupture (elastic tissue stain 100 x).
terial tree or pulmonary webs. All branches of
the pulmonary arterial tree were markedly
dilated and showed many elevated atheros-
clerotic plaques.
Fig. VII — Thickening of small pulmonary artery
(elastic tissue stain 100 x).
Sections of pulmonary parenchyma revealed
marked intimal thickening with narrowing of
the lumens of the pulmonary arterioles. So-
called glomus lesions and angiomatoid lesions as
described in severe pulmonary hypertension
were also present. There were no lesions in the
pulmonary parenchyma.
Fig. VIII — Angiomatoid lesion in lung — note thick-
ened vessels and dilated thin-walled vessels.
The heart weighed 450 grams and showed
marked right ventricular hypertrophy, the
thickness of the right ventricle being 0.9 cm.
The valves and left ventricle were normal.
There were no congenital heart defects. The
cervix showed radiation effect but there was no
evidence of residual tumor. No thrombi were
found in the pelvic veins or vena cava. The leg
veins showed excellent reflux bilaterally. The
liver showed severe chronic passive congestion
but no evidence of cardiac cirrhosis. The severe
congestion explains the elevated bilirubin and
transaminase.
Fig. IX — Severe passive congestion of liver.
— 28 —
JANUARY 1967
This patient had primary pulmonary hyper-
tension, a rare disease of unknown etiology
which exists in the absence of significant pul-
monary parenchymal or cardiac disorders.
60-90% of the patients are women, often in the
childbearing age group. Of course this disease
may also occur in children or in adult males.
The criteria for the diagnosis of this disease
include: 1) Absence of primary parenchymal
pulmonary disease — (such as fibrosis, granu-
loma formation, or decreased pulmonary func-
tioning mass) that may cause increased pressure
in the pulmonary circuit. None was found at
autopsy. 2) Right ventricular hypertrophy with
pulmonary hypertension — the former was
shown by autopsy, ECG and X-ray and the latter
at cardiac catheterization. 3) Normal pulmonary
wedge pressure — this was proved by cardiac
catheterization. 4) No left ventricular hypertrophy
— there was no evidence of this by ECG, fluoro-
scopy, or at autopsy. 5) No cardiac valve defor-
mities— There were none except for the rela-
tive tricuspid insufficiency caused by marked
right ventricular dilatation. 6) No congenital
heart disease — There was none. A possible
patent interauricular septum is suggested by the
cardiac catheterization O2 saturation data but
none was found at autopsy. 7) Pulmonary arterial
dilatation — The main pulmonary artery as well
as the primary and secondary branches were
markedly dilated. Small branches well beyond
the thrombus could be followed out to the peri-
phery of the lungs. 8) Pulmonary atheroscler-
osis — present. 9) Pulmonary arteriosclerosis of
medium and small arteries — present. This was
particularly striking with the elastic tissue
stains. The presence of plexiform and angio-
matoid lesions was also noted. 10) Absence of
source of peripheral emboli — This requires the
most discussion. Certainly there were no
thrombi in the pelvic veins. The leg veins
showed excellent reflux. Without completely
dissecting out the leg veins bilaterally, phlebo-
thrombosis cannot be completely ruled out.
However, we have no positive evidence for the
presence of thrombi in this case: the good reflux
and lack of leg edema, calf swelling, or asym-
metry, and the absence of clinical episodes of
either thrombophlebitis or pulmonary embolism
make the alternative of multiple pulmonary
emboli unlikely.
The presence of an antemortem organizing
thrombus in the pulmonary artery can be ex-
plained not on the basis of embolism, but on
the basis of thrombosis in a dilated arterios-
clerotic vessel. No other thrombi were seen in
small vessels and no evidence of old thrombi
such as pulmonary webs were seen. Also the
pulmonary arterial tree distal to the thrombus
was markedly dilated and atherosclerotic. This
might lead one to suspect that the thrombus
was secondary to turbulence and pulmonary
artery dilatation.
Primary pulmonary hypertension is thus a
diagnosis of exclusion. The causes of pulmonary
hypertension can be found in most textbooks.
These are listed below and can be ruled out in
this case. 1) Parenchymal pulmonary disease
such as emphysema, bronchiectasis, fibrocystic
disease, TBC, pneumonoconiosis, sarcoid, idio-
pathic pulmonary fibrosis (Hamman-Rich), con-
genital cystic lung disease and collagen disease
(scleroderma). 2) Pulmonary arterial obstruc-
tion from emboli, sickle cell anemia, cryoglo-
bulinemia, carcinomatosis, schistosomiasis and
arteritis. 3) Pulmonary hypoventilation with
secondary pulmonary vasoconstriction from
obesity (Pickwickian syndrome) or kyphos-
coliosis. 4) Pulmonary hypoventilation from
primary respiratory center damage. 5) Passive
pulmonary hypertension from mitral stenosis,
pulmonary vein obstruction, myxoma of left
atrium and left ventricular failure. 6) Hyper-
kinetic pulmonary hypertension from left to
right intra-or-extracardiac shunt such as ven-
tricular septal defect, auricular septal defect,
and patent ductus arteriosus. 7) Decreased pul-
monary tissue from surgery or disease. These
are all unlikely and we are left with primary
pulmonary hypertension. The progressive dys-
pnea and fatigue leading to cyanosis with severe
right heart failure is also characteristic of the
disease. The absence of clubbing is also usual.
The unique feature of this case was the rup-
ture of the pulmonary artery. I have not been
able to find another instance of this in the
literature. Dissecting aneurysms of the pul-
monary arteries have been reviewed by Foord
et al in the Archives of Pathology 1959. Liebow
discussed a ruptured dissecting aneurysm of the
pulmonary artery in a Clinicopathological Con-
ference in 1961. He also mentioned a case of his
own with congenital heart disease and pul-
monary hypertension which showed medione-
crosis of the pulmonary artery. However, a
case of rupture of the pulmonary artery with-
out dissection as was present in our case was
not found.
It is interesting that there was a great deal
of reaction and organization about the pul-
monary artery at the site of rupture. This means
that the process of disruption must have taken
— 29 —
SOUTH DAKOTA
place over a period of days and perhaps longer
before complete rupture with pericardial tam-
ponade ensued. There were areas of loss of
elastica in the pulmonary artery which could
be interpreted as mediocystic necrosis near the
site of rupture.
Syncope and sudden death have been seen in
primary pulmonary hypertension many times.
This has been attributed to decreased cardiac
output secondary to overload and failure of
the right heart which cannot compensate for
the increased venous return with increased out-
put. This leads to low left heart output and
coronary insufficiency. The increased end
diastolic pressure in the right atrium is also
thought to interfere with coronary artery filling
by increasing coronary sinus resistance. Thus
there is coronary artery insufficiency and myo-
cardial ischemia secondary to low cardiac out-
put and increased sinus resistance. Arrhythmias
may then occur causing sudden death.
In his investigations of primary pulmonary
hypertension James has described lesions of
arteries in S-A and A-V nodes which he be-
lieves cause arrhythmias. These arterial lesions
could explain syncope and sudden death in
primary pulmonary hypertension. The lesions
were not present in this case.
In summary, this is a patient with a rare dis-
ease, primary pulmonary hypertension, but with
a unique mode of death — rupture of the pul-
monary artery.
ANATOMICAL DIAGNOSES
Hemopericardium , 850 cc., with Pericardial Tampo-
nade
Rupture of Main Pulmonary Artery
Thrombosis of Main Pulmonary Artery, Organizing
Atherosclerosis of Pulmonary Artery and Major
Branches (Primary Pulmonary Hypertension)
Arteriosclerosis of P ulmonary Arterioles
Cor Pulmonale, Marked (Right Ventricular Wall
0.9 cm.)
Pulmonary Atelectasis, Diffuse , Moderate
Passive Congestion of Liver, Marked with Necrosis
Right Heart Catheterization (5 months)
Irradiation to Cervix (14. months) for Invasive Squa-
mous Cell Carcinoma
BIBLIOGRAPHY
1. Chapman, D. W., Abbot, J. P. and Watson, J.;
Primary Pulmonary Hypertension, “Circulation”
15, 35, 1957.
2. Yu, P.: Primary Pulmonary Hypertension, report
of six cases and review literature, “Annals of In-
ternal Medicine,” 49, 1138, 1958.
3. Sleeper, J. C., Organ, E. S. and McIntosh, H. D.:
Pulmonary Primary Hypertension, “Circula-
tion,” 26: 1358, 1962.
4. Heath, D. and Edwards, J. D., Configuration of
Elastic Tissue of Pulmonary Trunks in Idiopathic
Pulmonary Hypertension. “Circulation” 21:59,
1960.
5. James, T. N., On the Cause of Syncope and Sud-
den Death in Primary Pulmonary Hypertension,
“Annals of Internal Medicine,” 56:252, 1962.
6. McCaffrey et al, Primary Pulmonary Hyperten-
sion in Pregnancy, “OB Gyn Survey” August,
1964.
7. Naeye, R. L., Primary Pulmonary Hypertension
with Coexisting Portal Hypertension, “Circu-
lation”: 22:376, 1960.
8. Cohen, N. and Mendelow, H., Concurrent Active
Juvenile Cirrhosis and Primary Pulmonary Hy-
pertension, “American Journal of Medicine”; 39:
127, 1965.
9. Leibow, A. V. and Castleman, B. Case records of
Massachusetts General Hospital, “NEJM,” 265:18,
902, 1961.
10. Foord, A. G.; Lewis, R. D. Primary Dissecting
Aneurysms of Peripheral and Pulmonary Arteries,
“AMA Archives of Pathology” 68:553, 1959.
11. Braunstein, H. Periarteritis Nodosa Limited to
Pulmonary Circulation, “American Journal Path.”
31: 1955.
12. Naeye, R. L., Arterial Changes During Perinatal
Period, “AMA Archives of Path.” 71:121, 1961.
13. Kanjuh, V. I., Sellers, R. D., Edwards, J. E., Pul-
monary Vascular Plexiform Lesion, “AMA
Archives of Path.” 78:513, 1964.
14. Rudolph, A. M., Nadas, A. S.; Pulmonary Circu-
lation and Congenital Heart Disease “NEJM”
267: 968, 1962, (two parts of Medical Progress).
15. Moschowitz, E., Rubin, E. and Strauss, L.: Hyper-
tension of Pulmonary Circulation Due to Con-
genital Glomoid Obstruction of Pulmonary Ar-
teries: American Journal Path.” 39:75, 1961.
16. Rubin, E., and Strauss, L.: Occlusive Intrapul-
monary Vascular Anomaly in Newborn: Cause of
Congenital Pulmonary Hypertension? “American
Journal Pathology” 39:145, 1961.
17. Heath, D. and Edwards, J. E.: The Pathology of
Hypertensive Pulmonary Vascular Disease, “Cir-
culation” 28:533, 1958.
18. Arias, Stella J.; Penaloza, D., Severino, J.; Path-
ology of Primary Pulmonary Hypertension —
Study Serial Sections “American Journal Path-
ology” 35:668, 1958 (Abstract).
19. Cross, K. R., Kobayoski, C. K.: Primary Pulmon-
ary Vascular Sclerosis — Report of Case “Amer-
ican Journal Clinical Pathology” 17:155, 1947.
20. Hufner, R. F., McNicol, C. A.: Pathologic Physio-
logy of Microscopic Pulmonary Vascular Shunts
“AMA Archives of Pathology” 65:554, 1958.
21. Dowminy, S. E., Vidone, R. A., Brandt, H. M.,
Unebow, A. A.: The Pathogenesis of Vascular
Lesions in Experimental Hyperkinetic Pulmonary
Hypertension, “American Journal Pathology”
43:739, 1963.
22. Hruban, Z., Humphreys, E. M.: Congenital Ano-
malies Associated with Pulmonary Hypertension
in an Infant: “AMA Archives of Pathologv” 70:
733, 1960.
23. Naeye, R. L. and Vennart, G. P.: Structure and
Significance of Pulmonary Plexiform Structures,
“American Journal Pathology” 36: 563, 1960.
24. Edwards, J. E.: Functional Pathology of the Pul-
monary Vascular Tree in Congenital Cardiac Dis-
ease, “Circulation” 15:164, 1957.
25. Gordon, A. J., et al: Patent Ductus Arteriosus
with Reversal of Flow “NEJM” 251:923, 1954.
26. Wagenvoort, C. A., Neufeld, N. H., and Edwards,
J. E.: Structure of Pulmonary Arterial Tree in
Fetal and Early Postnatal Life, “Lab Investi-
gation” 10:751, 1961.
27. Wagenvoort, C. A.: Pulmonary Arteries in Infants
with Ventricular Septal Defect, Quantitative
Study of Anatomic Features in Fetuses, Infants,
and Children, “Circulation” 23:750, 1961.
28. Wagenvoort, C. A.: Vasoconstriction and Medial
Hypertrophy in Pulmonary Hypertension. “Cir-
culation” 22: 535, 1960.
29. Barlow, J. F. and Cutshall, V. K., Clinicopatho-
logical Conference — Sioux Valley Hospital.
“So. Dak. Jour, of Med.” Vol. XIX, No. 11, 1966.
— 30
ADENOID CYSTIC CARCINOMA OF THE
MIDDLE EAR AND MASTOID CAVITY
WITH A CASE REPORT
Richard J. Weaver, M.D.
Sioux Valley Hospital
Sioux Falls, South Dakota
and
Lothar Kaul, M.D.
2010 West 33rd Street
Sioux Falls, South Dakota
Malignant tumors of the middle ear and mas-
toid are uncommon. Most often they are squa-
mous carcinomas. Rarely are they adeno-
carcinomas. A review of the literature by Jaffee
and Page in 1961 showed only 120 malignancies
recorded in this site, and of these, only six were
adenocarcinomas. They added a seventh case.
So far as we know, these seven cases of adeno-
carcinoma in this site are the only cases to have
been reported to date, and we wish to add the
eighth.
CASE REPORT
The patient, Mr. R., a 50-year old white male, was
seen the first time in September of 1960, complaining
of a hearing loss in the right ear dating from about
three to six months prior to his consultation. The
examination at that time showed a right serous
otitis media. A myringotomy was done and a large
amount of serous fluid was obtained from the middle
ear.
The patient ignored the appointment to return
to the office and returned by himself about 1V2 years
later. At that time he was again complaining of a
hearing loss in the right ear; also, that he had lost
part of the vision in the right eye, and had an im-
pairment of the function of the movement of the
right eyeball. X-rays of the mastoids and sinuses at
this time revealed a partially sclerotic mastoid on
the right side. The left mastoid was normal, as were
the paranasal sinuses.
Several months later the patient accepted the sug-
gestion of the otolaryngologist and of his local phys-
ician and went for further examination and treat-
ment to a large clinic. After examination, a surgical
exploration of the cerebellopontine angle was done
and a small cyst with thickened arachnoid was
found. The mastoid and ear problem at that time
was evidently disregarded.
A year and a half after this operation, and three
years after the first consultation, the patient returned
to the office with drainage from his right ear and a
so-called Gradenigo complex.
In October, 1964, a radical mastoidectomy was
performed. The mastoid cavity was found to be
filled with a chronically infected and thickened mem-
brane. Further exploration of the middle ear showed
a tumorous mass filling every space of the middle ear
and extending anteriorly and medially.
At the time of the operation, as far as it was
possible, all the tumorous tissue within the middle
ear and the anterior portion of the petrous bone, in-
cluding the ossicles, were removed, and the procedure
was completed as a radical mastoidectomy.
Grossly the specimen removed at surgery consisted
of a gray-pink rubbery piece of tissue 0.7 x 0.4 x
0.2 cm. and two smaller gray-tan fragments 0.2 x
0.5 cm. in greatest dimensions.
Fig. 1. Adenoid cystic carcinoma of mastoid cavity.
H & E. 35X.
Fig. 2. Adenoid cystic carcinoma of mastoid cavity
and middle ear. H. & E. 100X.
— 31 -
SOUTH DAKOTA
Fig. 3. Adenoid cystic carcinoma of mastoid cavity
and middle ear. H. & E. 400X.
Microscopically (Figures 1, 2, and 3), the specimen
showed a dense fibrous stroma in which were small
irregular glandular spaces lined by epithelium which
appeared to vary considerably in height. The glands
were hyperplastic and in some areas were back-to-
back. The smaller glands were lined in cuboidal or
low columnar epithelium. The nuclei were basalad
and uniform in appearance.
The specimen was seen in consultation by the
A.F.I.P. (Dr. S. H. Rosen) who concurred in the diag-
nosis of adenoid cystic carcinoma of the mastoid
cavity.
After surgery the patient received cobalt therapy.
In the following months the patient has been ex-
amined several times and the mastoid cavity appears
to have healed satisfactorily.
DISCUSSION
Adenoid cystic carcinoma arises from gland-
ular elements or mucous membrane in many
locations. We have seen it most frequently in
salivary glands and the breast. Recently, two
cases have been reported from the uterine cer-
vix,8- 9 and we hope presently to add a third to
the literature. It is also extremely rare in the
middle ear, this being, so far as we know, only
the eighth reported case.
Chronic infections of the middle ear and/or
mastoid can result in squamous metaplasia of
the mucous membrane from which the more
common squamous carcinomas probably arise.
Signs and symptoms which may occur with
malignancies of the middle ear include pro-
longed otorrhea, pain, bleeding, invisible growth
through the external canal, hearing loss, facial
palsy, paralysis, vertigo, tinnitus, and tender-
ness over the mastoid area.
Prognosis in this disease heretofore has been
very poor. Previously, radical surgery was
thought to offer the best chance of palliation
and was usually followed by x-ray therapy.
Cures for any length of time have been un-
known although Grabscheid reported a case in
1943 who was alive four years after radical sur-
gery and x-ray.
Our patient received cobalt therapy follow-
ing surgery and is doing well twenty-six months
after surgery and diagnosis. The mastoid cavity
and middle ear are dry although the eye symp-
toms remain the same.
SUMMARY
We have reported, insofar as we know, the
eighth case of adenoid cystic carcinoma of the
middle ear. Tumors of the middle ear are rare,
only 120 having been reported by Jaffee and
Page in 1961.
Prognosis heretofore has been poor. Our pa-
tient received cobalt therapy after surgery and
appears to be doing well twenty-six months
after the original surgery.
BIBLIOGRAPHY
1. Campbell, Volk and Burklund: Total Resection of
Temporal Bone for Malignancy of the Middle Ear,
Annals of Surgery, 134:397, September, 1951.
2. Conley and Novack: Surgical Treatment of Malig-
nant Tumors of Ear and Temporal Bone, Archives
of Otolaryngology, 71:635, April, 1960.
3. Ellis, Maxwell and Pracy: Carcinoma of the Middle
Ear, British Medical Journal, 1:1413, June 19. 1954.
4. Figi and Weisman: Cancer and Chemodectoma in
the Middle Ear and Mastoid, Journal American
Medical Association, 156:1157, 1954.
5. Furstenberg, A. C.: Primary Adenocarcinoma of
the Middle Ear and Mastoid, Annals of Otolaryn-
gology, Rhinology, and Laryngology, 33:677, 1924.
6. Grabscheid, Eugen: Adenocarcinoma Involving the
Middle Ear, Archives of Otolaryngology, 37:430,
1943.
7. Jaffee, S. and Page, R.: Adenocarcinoma of the
Middle Ear, Laryngoscope, 71:392-5, 1961.
8. McGee, J. A., et al: Adenoid Cystic Carcinoma of
the Cervix, Obstetrics and Gynecology, July-Dee.,
26:356-8, 1965.
9. Tchertkoff, V. and Sedlis, A.: Cylindroma of the
Cervix, American Journal Obstetrics and Gyne-
cology, Vol. 84:749-752, 1962.
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— 32 —
Giant Pericardial Cyst with Cardiac Manifestations
Thomas J. Yeh, M.D., Assistant Professor of Surgery (Thoracic) and
Isam N. Anabtawi, M.D., Instructor in Surgery (Thoracic)*
A pericardial cyst very rarely causes symp-
toms, and as a rule the lesion is removed only
because it must be differentiated from a medias-
tinal tumor. A few exceptions have appeared in
the English literature; among those are the
cases reported by Churchill and Mallory,1
Lam,2 Shidler and Holman,4 and Ross and
Ramos.3 Dysphagia, dyspnea and cyanosis were
prominent symptoms. In each of these cases the
symptoms were completely relieved by excision
of the cyst. This is a case report of a patient
with a giant pericardial cyst producing dyspnea
and assorted objective cardiac manifestations,
posing an interesting diagnostic problem.
REPORT OF A CASE
H. K., a 55 year old man was admitted to Eugene
Talmadge Memorial Hospital on 7-6-65 because of a
large mediastinal mass. The lesion was first noted
about 11 months previously. About 9 months pre-
viously he had great difficulty with dyspnea accom-
panied by ankle swelling, for which he was digitalized
with partial improvement. On examination at ad-
mission he was 195 cm tall, and had a marked ky-
phosis and a slight roto-scoliosis. The blood pressure
was 140/90 mm Hg. A paradoxical pulse of 20 mm
Hg at rest and 30 mm Hg on deep respiration was
noted. The left precordium was protuberant and a
forceful cardiac pulsation was visible. The apical
impulse was diffuse and heaving. The area of car-
diac dullness extended to the left anterior axillary
line. A grade III harsh systolic murmur was heard
at the pulmonic area during expiration, nearly dis-
appearing during inspiration. The liver was palpable
but not pulsatile. Electrocardiogram was interpreted
as chronic cor pulmonale and possible old myocardial
infarction. The Master’s two step test failed to show
additional ischemia. Chest X-ray and cardiac obliques
showed a large anterior mediastinal mass extending
into both hemithoraces, displacing the esophagus pos-
teriorly to the left. A normal cardiac shadow could
be discerned as a double density within the mass on
PA projection (Fig. 1 a. b. c.). The clinical diagnosis
was mediastinal tumor with cardiac compression and
possible old myocardial infarction.
On July 21, 1964 he was explored through a right
posterolateral thoracotomy. A huge, tense cyst with
transmitted pulsation was found behind the heart,
bulging partially into the right hemithorax. The bulk
of the cyst was in the left hemithorax, displacing and
compressing the heart against the anterior chest wall.
*
During dissection the cyst was ruptured and 3000 cc’s
of clear, watery fluid were aspirated. The cyst wall
was completely removed. No communication with
bronchus or pericardial space was demonstrated. On
microscopic examination the cyst wall was composed
of a thin layer of dense fibrous tissue with meso-
thelial lining. The murmur, the prominent pre-
cordial pulsation, the paradoxical pulse, hepatomegaly
and dyspnea all disappeared and he was discharged
home on the 7th postoperative day. Follow-up chest
X-ray revealed a normal sized heart (Fig. 2). When
last seen on November 19, 1964, five months after sur-
gery, he was symptom-free. Pulmonary function
study showed a great improvement. (Table 1).
Fig. 1. a. b. and c. Preoperative chest X-rays in PA.
right anterior oblique and left anterior oblique views
showing large mass superimposed on normal cardiac
shadow.
From the Department of Surgery (Thoracic), Med-
ical College of Georgia, Augusta, Georgia.
— 41 —
SOUTH DAKOTA
Fig. lc
Fig. 2. Postoperative chest X-ray.
DISCUSSION
All of the cardiac findings disappeared after
surgery and can therefore be attributed to the
presence of the mass. The paradoxical pulse,
no doubt, was due to interference with cardiac
filling, the murmur due to pulmonary artery
compression, precordial heave due to displace-
ment of the heart, and hepatomegaly due to dis-
placement of the liver. Pericardial effusion as
a diagnosis was effectively ruled out by the
X-ray findings of a separate distinct heart
shadow within the mass on PA view.
SUMMARY
A 55 year old patient with an unusually large
pericardial cyst containing 3000 cc’s of fluid,
and producing a heart murmur, precordial
heave, paradoxical pulse, hepatomegaly, and
dyspnea, has been presented. Because of these
findings, the nature of the mass lesion was not
clarified before thoracotomy. All symptoms
and signs disappeared upon surgical removal of
the cyst.
— 42 —
JANUARY 1967
TABLE 1.
Pulmonary Function Before and After Excision of the Pericardial Cyst
Timed
Vital Capacity
Vital Capacity
1 second 3 seconds
Maximal Voluntary Ventilation
ml
%
%
L/min.
Predicted Normal
4450
75
95
153
Preoperative
(July 8, 1964)
4034
63
100
80
Postoperative
(Nov. 19, 1964)
6460
75
100
124
REFERENCES
1. Churchill, E. D., and Mallory, T.: Case Records
of the Massachusetts General Hospital, Case
23492, New Eng. J. Med. 217: 958, 1937.
2. Lam, C. R.: Pericardial Celomic Cyst, Radiology
48: 239, 1947.
3. Ross, C. A., and Ramos, A. G.: Giant Pericardial
Cyst, Amer. Rev. Resp. Dis. 85: 895, 1962.
4. Shidler, F. P., and Holman, E.: Mediastinal
Tumors; Presentation of 34 cases, Stanford M. Bull.
10: 217, 1952.
DESIDERATA*
(Found in old St. Pauls Church, Baltimore, dated 1692 and kept by Adlai Stevenson on his bedside table.)
Go placidly among the noise and the haste and learn what peace there may be in silence.
Speak your truth quietly and clearly; and listen to others, even the dull and the ignorant; they too
have their story.
If you compare yourself with others you may become vain and bitter; for always there will be
greater and lesser persons than yourself.
Enjoy your achievements as well as your plans. Keep interested in your career, however humble; it
is a real possession in the changing fortunes of times.
Exercise caution in your business affairs; for the world is full of trickery. But let not this blind
you to what virtue there is; many persons strive for high ideals and everywhere life is full of
heroism.
Be yourself. Especially do not feign affection. Neither be cynical about love; for in the face of all
aridity and disenchantment it is perennial as the grass.
Take kindly the counsel of years, gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune, but do not distress yourself with
imaginings.
Many fears are born of fatigue and loneliness.
Beyond a wholesome discipline, be gentle with yourself. You are a child of the universe no less
than the trees or the stars. And whether or not it is clear to you no doubt the universe is unfolding
as it should.
Therefore be at peace with God, whatever you conceive him to be. And whatever your labors and
aspirations in the noisy confusion of life keep peace with your soul.
With all its sham, drudgery and broken dreams, it is still a beautiful world.
(^DESIDERATA — plural of DESDERATUM, which means anything desired as essential or needed.)
— 43 —
Path C APsule
Submitted by the College of American Pathology in
connection with the South Dakota Society of Pathol-
ogists.
THE DIAGNOSTIC VALUE
OF URINARY STEROIDS
The steroid hormones include a number of
complex compounds which regulate water and
electrolyte excretion, affect the metabolism of
carbohydrates, fats and proteins, and are essen-
tial to sexual development and function. The
steroid hormones are synthesized in the adrenal
glands and in the gonads; the activity of these
organs is regulated by the pituitary. It is ap-
parent that various hypoplasias, hyperplasias
and neoplasms are capable of producing many
disease states when these organs are involved.
A portion of the steroid hormones and their
metabolites is excreted in the urine and can be
measured quantitatively. The amount excreted
is closely related to the functional activity of
adrenals and gonads. Therefore, it is possible to
detect functional abnormalities involving these
structures by an analysis of the amount of the
various metabolites excreted in the urine.
There are three frequently measured steroid
fractions. All have the same basic structural for-
mula. The 17-ketosteroids are those compounds
which have a keto group on Carbon-17 of the
steroid nucleus, and the 17-hydroxycortico-
steroids and Porter-Silber chromogens are those
compounds which have a hydroxyl group on
Carbon-17 of the steroid nucleus. For the sake
of clarity these three classes of compounds will
be discussed separately.
17-Kelosieroids: In males approximately two-
thirds of the 17-ketosteroids are derived from
androgens produced by the adrenal cortex and
one-third from the androgens produced by the
testes. In females almost all of the 17-ketosteroids
arise from androgenic compounds manufactured
by the adrenal cortex. The level of 17-keto-
steroid excretion in the female is therefore a
measure of androgen activity. However, in the
male it does not constitute a measure of all an-
drogens, because testosterone, the most potent
androgen of all, is not a 17-ketosteroid.
The measurement of 17-ketosteroids is used
primarily as an index of adrenal cortical func-
tion but is inferior to the measurement of 17-
hydroxycorticosteroids. Moreover, a significant
amount of urinary 17-ketosteroids may be de-
rived from breakdown of non-androgenic ster-
oids, mainly in the liver, and occasionally levels
of 17-ketosteroid may be affected by alterations
of hepatic metabolism.
17-Hydroxycorticosteroids: These compounds
are frequently referred to as Ketogenic Steroids
because they can be converted easily to 17-
ketosteroids in the laboratory. The advantage
of converting them to 17-ketosteroids is that
they can then be measured by the same pro-
cedure used to measure the normally occurring
17-ketosteroids.
The 17-hydroxycorticosteroids are produced
entirely by the adrenal cortex and are involved
in carbohydrate, protein, water and electrolyte
metabolism. The measure of 17-hydroxycorti-
costeroids is considered by many to be the best
laboratory assessment of adrenal cortical func-
tion. Therefore, elevation or diminution of 17-
hydroxycorticosteroids can point to hyperplasia,
hypoplasia or neoplasia of these organs.
Porter-Silber Chromogens: These compounds
include mainly cortisone and hydrocortisone.
They are actually a part of the 17-hydroxycorti-
costeroid fraction. However, in the laboratory
the Porter-Silber chromogens can be separated
from the other 17-hydroxycorticosteroids. The
Porter-Silber chromogen fraction is elevated in
Cushing’s syndrome.
Using the three measurements described, the
findings in some important diseases are pre-
sented in tabular form (Table I).
TABLE I
Urinary Steroid Values in Various Diseases
Clinical State
17-Hy-
droxy
Porter-
Silber
17-Keto
Cushing’s syndrome
+ +
+ +
N/+
Addison’s disease
—
—
—
Cirrhosis
N/+
N/ +
—
Aldosteronism
N
N
N
Pituitary failure
—
—
—
-f — increased — = decreased N — Normal
— 44 —
JANUARY 1967
Normal Values: Table II.
Specimen: Aliquot of 24 hour urine collection.
Collection of Specimen: Urine for 17-keto-
steroids may be collected in 15 ml. of concen-
trated hydrochloric acid. Urine for 17-hydroxy-
corticosteroids and Porter-Silber chromogens
must not be collected in acid and should be kept
refrigerated.
Certain drugs such as paraldehyde interfere
with the determination of Porter-Silber chromo-
gens. It is preferred to withhold all medication
48 hours prior to collection of urine for any of
these determinations.
TABLE II
NORMAL VALUES OF URINARY STEROIDS
17-KETOSTEROIDS
(mg/24
hrs.)
Age (Yrs.) 0-14 days 0-3
3-6
6-8
8-10
MALE
or 1.5-2. 5 0-0.5
0-2.0
0-2.5
0. 7-4.0
FEMALE
Age (Yrs.) 10-12 12-14
14-16
16-50
60-90
MALE 0. 7-6.0 1.3-10
2.5-13
10-20
20-5
FEMALE 0. 7-5.0 1.3-8.5
2.5-11
5-15
13-3
17-HYDROXYCORTICOSTEROIDS
(mg/24 hrs.)
(Ketogenic Steroids)
Age (Yrs.) 0-3 3-6 6-10
10-14
14-50 Over 50
MALE
8-20
4-14
1-4 1-6 2-8
2-10
FEMALE
5-14
2-10
PORTER-SILBER CHROMOGENS
(mg/24
hrs.)
(Mainly Cortisone & Hydrocortisone)
Age 0-3 3-6 6
-10
10-14
Adult
MALE
4-12
2-4 3-6
4-8
4-10
FEMALE
4-8
REFERENCES
Gerson R. Biskind, Workshop on Hormone Assay
Manuals 1959 Am. Soc. Clin. Path., Chicago.
Sunderman, F. W. and Boerner, F., Normal Values in
Clinical Medicine 1949 W. B. Saunders Company,
Philadelphia.
Page, L. B. and Culver, P. J., Syllabus of Laboratory
Examination in Clinical Diagnosis, 1961, Harvard
University Press, Cambridge.
Wilkins, L., The Diagnosis and Treatment of En-
docrine Disorders in Childhood and Adolescence,
Charles C. Thomas, 1962.
O’Brien, D., and Ibbott, F. A., Laboratory Manual of
Pediatric Micro-and Ultramicro- Biochemical Tech-
niques, 3rd Edition, 1962, Harper and Row.
ELECTROPHORESIS
The greatest unrealized potential value of
the technique of electrophoresis lies in its use as
a screening test similar to routine urinalysis and
complete blood counts in the initial work-up of
a patient. Used in this manner a normal report
has great value in itself ruling out whole cate-
gories of serious diseases. When abnormal,
it points the way to more specific tests and
in certain instances permits a pathognomonic
diagnosis.
Normal values are established in each lab-
oratory on the basis of experience with a large
number of sera (a hundred or more) from
healthy persons of various ages from childhood
to senescence. See Table IA. It is important
to keep in mind the changing values of gamma
globulin during infancy.
Table IB.
Abnormal patterns have been observed with
significant frequency in the diseases listed in
Table II. With increasing use as a screening
procedure earlier changes from normal may be
observed in these and other disease states. The
development of cellulose acetate paper and
starch gel methods yielding more fractions may
also add some refinements to differential diag-
nosis of abnormal patterns.
Finally electrophoresis is the most specific
method to diagnose sickle cell anemia, Thalas-
semia and other inherited hemoglobinopathies.
TABLE IA
NORMAL RANGE
Albumin
54-70%
3. 7-5. 5 g/100 ml
Alphai Globulin
2- 5%
0. 1-0.3 g/100 ml
Alpha? Globulin
7-11%
0. 4-1.0 g/100 ml
Beta Globulin
8-14%
0.5-1. 1 g/100 ml
Gamma Globulin
10-20%
0.5-1. 2 g/100 ml
TOTAL
100%
6.2-8. 1 g/100 ml
It has been suggested by eugenists as a means
of screening large numbers of high school chil-
— 45 —
SOUTH DAKOTA
dren to detect the heterozygous state as an
adjunct to premarital counseling.
S.D.S.M.A. LOSES SUPREME COURT
DECISION
TABLE IB
GAMMA GLOBULIN (g/100 ml)
Age of Paiieni
Mean Value
Normal Range
1 week
0.7
0.4-0. 9
1-3 mo.
0.3
0.2-0. 4
3-6 mo.
0.4
0.2-0. 6
6-12 mo.
0.5
0.3-0. 7
12-18 mo.
0.6
0.4-0. 8
18-24 mo.
0.8
0.5-1. 1
Over 2 yrs.
Rapid increase to
Normal Adult Values
TABLE II
ABNORMAL ELECTROPHORESIS
ASSOCIATED WITH DISEASE
TP A ai
a2
B
Y
—
+
Acute infection
—
+
—
Asthma, other Allergies with Poor
Response to Therapy
— +
+
Carcinomatosis
—
+
Chronic Infection
+
Cryoglobulinemia —
(isoelectric band)
—
+
+
Diabetes Mellitus
—
+
Glomerulonephritis
— —
+
Hepatic Cirrhosis —
(merger of B — y peaks)
—
—
+
+
Hepatitis, Viral
—
+
+
Hodgkins Disease
—
—
Hypogamma globulinemia
—
+
Leukemia, Myelogenous
—
+
+
Lupus Erythematosis
—
—
Lymphoma and Lymphocytic
Leukemia
+ —
+
+
Macroglobulinemia
+ —
+
Myeloma — (Narrow Homogeneous
Band between a-2 and y)
..... —
+
Myesthenia
—
+
+
Myxedema
—
+
■
Nephrosis —
(Highest ao Elevation)
+
Rheumatic Fever
+
+
Rheumatoid Arthritis
+ —
+
+
+
Sarcoidosis
Scleroderma
+
+
—
—
Ulcerative Colitis, other
exudative enteropathies
-f = increase
— = decrease
BIBLIOGRAPHY
1. Sunderman, F. W. Jr., Studies of the Serum Pro-
teins VI. Advances in Clinical Interpretation of
Electrophoretic Fractionations. Amer. J. Clin. Path.
42, No. 1, July 1964.
The South Dakota Supreme Court reversed a
decision that made property of the South Da-
kota State Medical Association exempt from
taxation.
The Supreme Court ruled in favor of the Min-
nehaha Board of County Commissioners, which
had appealed a verdict in Minnehaha County
Circuit Court. The circuit court found a part of
the real property was exempt.
The Supreme Court said that the objectives
of the association are laudable and it is evident
that dissemination of health information and
other public services by the group are of benefit
to the public. But the court added that there
are elements of personal advantages and profit
to members of the association and it does not
qualify as being “exclusively” for benevolent
purposes.
standard and custom
EVEREST & JENNINGS
FOLDING
WHEEL
CHAIRS
ALSO
WALKERS
CRUTCHES
PATIENT LIFTS
COMMODES
Rentals * Sales
Kreiser Surgical, Inc.
Sioux Falls Rapid City
46 —
DEADWOOD DOCTOR
By F. S. Howe, M.D.
CHAPTER VII
Deadwood Politics
I got into Deadwood politics accidentally and
stayed in for 19 years because I’ve never be-
lieved in backing away from a good fight.
In 1917 I was appointed to the city council
as an alderman from the third ward to take the
place of a member of the council who had left
Deadwood. I was a member of the council for
7 years. During much of that time I was presi-
dent of the council and chairman of the finance
committee.
About 1922, the Board of Education of the
Deadwood school district decided that our old
out-dated building must be replaced by a new
and modern building. In order to get the neces-
sary public support to pass a bond issue, they
called public meetings. For a time these public
meetings were a regular love feast. It seemed
the unanimous opinion that Deadwood must
have more modern school buildings. George
V. Ayres proposed that we ask for a $250,000
bond issue. That almost took my breath away,
but I thought if a man of Mr. Ayres’ experience
believed that was what we needed, who was I
to oppose it? At a later, and I believe the
last meeting, W. E. Adams, who was then
mayor, got up and said, “$50,000 and not one cent
more.” Being mayor and the leading citizen of
Deadwood at that time, that certainly threw a
monkey wrench in the machinery.
This meeting really became hot. The late
Charlie Keene who was enthusiastically for the
new school facilities immediately got up and
shook his finger in Mr. Adams’ face and said,
“What this here town needs is some first class
funerals.” Then the fight was on.
Mr. Adams lined up the Homestake Mining
Company, both the C.B. & Q. and C. & N.W.R.R.
Companies, and Horace Clark, the heaviest in-
dividual tax payer and property owner in Dead-
wood. Needless to say, this fight really became
bitter. When election day finally came around,
both sides were getting out every vote that
could be found. Late in the afternoon, I found
that the then Methodist minister and his wife
had not voted. I made a trip to the house and
the minister himself came to the door. I said,
“Reverend K , you have not voted yet. We
need your vote.” Much to my disgust, the
Reverend said, “This is nothing but an old down
and out mining camp. You don’t need any new
school.” I told him that he should go and vote
against it if that was the way he felt.
We finally won out by a substantial majority
in spite of all the opposition. However, our
troubles were not over. Chambers Kellar, the
Chief Attorney for the Homestake Mining Com-
pany, decided to go to court. A committee
which, as I remember, was headed by me, had
a conference with Mr. Kellar and he finally
agreed on a $175,000 issue instead of the $250,000
issue. Otherwise it would have to be decided
by the courts. We had the architects draw up
new plans and sold the bonds. The best bid
which we could get was $3,000 under par. Mr.
Kellar stuck to his guns and said we had to get
par for the bonds or make up the amount. In
short order we raised the extra $3,000 and the
contract was let.
Our present school was dedicated in 1924 and
it now seems strange that we should have had
such a bitter fight to get modern school build-
ings with gymnasium and auditorium. Cham-
bers Kellar afterwards became one of my very
best friends and up until the time of his death
I admired and respected him.
It goes without saying that this fight was not
over, however. In 1924 I was approached by a
great many of my friends to run for mayor. My
petition was circulated and very generally
signed. The Adams’ forces tried in every way
to agree on a compromise candidate but inas-
much as I had agreed to run I informed them
that I was in the fight to the finish. Mr. Adams'
campaign manager informed me that in that
case Mr. Adams would personally run and as he
had never been beaten, I was in for sure defeat.
I informed him if the people decided they were
satisfied with the old regime, that would be fine
with me. Our campaign slogan was “Progress
and Economy.” The opposition repeatedly
stated that progress and economy could not and
would not go together. When the votes were
counted, I had won by a very substantial ma-
jority. One of Deadwood’s leading attorneys
said that there were not that many votes in
Deadwood, that we had certainly found a lot of
votes in Mt. Moriah. So far as I know, neither
side voted Wild Bill or Calamity Jane, but you
can be sure that both picked up every vote
possible.
I served for 6 terms as Mayor and paid off
a $100,000 debt, leaving the city debt free, ex-
cept for some paving bonds which were a lien
against property only. The next bitter fight
was an attempt to change the form of govern-
47 —
SOUTH DAKOTA
ment and thus remove me from office. This
fight was more bitter than any of the preceding
fights and we won by a substantial majority. As
soon as the election was over, my attorney, John
T. Heffron, began suit against the Deadwood
Pioneer-Times for libel, for what they had
called me in the campaign. They made the
necessary apology in their papers which my
attorney said was legal. To me, it seemed to
mean very little.
When the Adams Museum (a gift of my long
time political enemy) was dedicated, as Mayor
of Deadwood, I was supposed to accept it in the
name of the city. I was asked to be one of the
speakers. Mr. Adams wasn’t in a position to ask
me so he got a friend to make the request. I
said that I would be very happy to accept it as
Mayor for the city, which I did. E. W. Martin,
former Congressman, Dr. O’Hara, President of
the School of Mines, Senator Bulow, and my-
self were the principal speakers. W. E. Adams
and I were bitter political enemies but we both
loved Deadwood.
One of the very amusing incidents which
happened during one of my terms as mayor was
when the osteopathic doctors had their annual
meeting in Deadwood. Dr. Wasner of Deadwood
was president and asked me to make the wel-
coming address as mayor. I was very happy
to do that but wondered just what a doctor
could say to the osteopaths. I went to my good
friend, John T. Heffron, for advice, and after
listening to my story, he said, “You are in a
hell of a mess.” Finally, however, I decided that
I would make a very brief welcoming speech
and then give the boys a talk on Wild Bill,
Calamity Jane, Poker Alice, Deadwood Dick
and so on. After I had talked for some time, I
said, “Well, boys, I think it is time for me to
quit.” They said, “No, go on, we are enjoying
it.” I also enjoyed it.
The high point of my career as Mayor of
Deadwood, of course, came in the year 1927 when
President Coolidge spent the summer at the
State Game Lodge in the Black Hills. When
President Coolidge arrived early in the month
of June, we immediately got in touch with his
secretary and made an appointment to see him
at his office in the Rapid City high school build-
ing and invited him to be our guest at the Days
of '76 celebration, the first week of August,
1927. Our committee was headed by the late
Judge Rice. Other members of the committee
were John T. Heffron, City Attorney, Fred
Gramlich, representing the Chamber of Com-
merce, Lee Boyer and myself as Mayor. The
Deadwood Chamber of Commerce selected a
beautiful rod and reel which was to be our peace
offering to him when we gave him the invi-
tation to come to Deadwood. Judge Rice was
our spokesman.
One of the members of our party was carry-
ing a small mysterious looking package wrapped
in a newspaper. We were all very curious as to
what it was and the Secret Service men looked
on him with great suspicion — in fact, watched
him every minute. After Judge Rice had pre-
sented the rod and reel together with our in-
vitation, which was, of course, done in a very
beautiful and masterly manner, the President’s
party as well as our party turned to leave, think-
ing that the ceremony was over. Just at that
time the member of our party who carried the
package stepped out and said, “Just a minute,
Mr. President. I have here a jar of wild
raspberry jam made from berries picked by
my wife and the jam itself was made by my
wife.”
Everybody seemed very much amused except
the members of our party. To say that we were
embarrassed is an understatement. For a long
time after, the members of our committee had
to submit to many jokes at our expense.
When the days of the celebration arrived, the
President and his party boarded a special Bur-
lington train at Custer, South Dakota, and came
to Deadwood. Colonel Starling, Chief of the
Secret Service, preceded the party and made
complete arrangements in every detail as to the
line of march and just how the streets should be
roped off, etc. Deadwood had the largest crowd
in its history on the day that President Coolidge
was our guest. President and Mrs. Coolidge
went to the grounds in my open Cadillac car.
Mrs. Howe and myself occupied the box with
President and Mrs. Coolidge. We found Mrs.
Coolidge one of the most charming women we
have ever met. President Coolidge was not
nearly so silent as some of the correspondents
would have had us believe.
The big event of the day was when the Sioux
Indians, of which there were some five or six
hundred present, called the President out of his
box, made him a member of the Sioux Tribe
and called him Chief Leading Eagle. They
placed on his head a most ornate and beautiful
feathered headpiece with the feathers trailing
on the ground. It was really a beautiful hand-
made piece of work. President Coolidge, how-
ever, seemed rather embarrassed, although I
think he was pleased. The high point of Presi-
dent Coolidge’s stay in the Black Hills was, of
— 48
JANUARY 1967
course, his announcement, “I do not choose
to run.” I still remember the efforts that were
made to place a different interpretation on the
President’s words but with Coolidge, “I do not
choose to run” meant just what it said: “I will
not be a candidate.”
Many amusing stories have been told of
President Coolidge’s stay in the Black Hills.
When I first met President Coolidge the day
after his arrival in the Hills, I was shocked at
his emaciated appearance, but before he left he
did not look like the same man. President and
Mrs. Coolidge attended the little church in the
small town of Hermosa, some 20 miles from
the Game Lodge, on Sundays. One story that
has gone the rounds was that on one Sunday
morning Mrs. Coolidge, not feeling too well,
decided to stay home. The President went to
church as usual. During the dinner hour, Mrs.
Coolidge asked President Coolidge, “What did
the preacher talk about today?” His answer
was “Sin.” She asked further, “What did he say
about it?” Again his answer was brief, “He was
against it.”
(To be Continued)
South Dakota Regional Heart, Cancer
and Stroke Program is presently taking
applications for the position of Director.
This position may be filled by either a
medical doctor or a person with back-
ground in medical administration, hospital
administration or related fields. Salary is
open. Please contact Richard C. Erickson,
Executive Secretary, South Dakota State
Medical Association, 711 North Lake
Avenue, Sioux Falls, South Dakota 57104.
THE PHYSICIAN'S ROLE IN BLUE SHIELD
Thanks to the pioneering of physicians and
community leaders who began establishing Blue
Shield Plans over 25 years ago, some 53 million
Americans today have protection against the
costs of physicians’ services under this unique
prepayment system.
Blue Shield was organized by physicians and
supported by medical societies at a time when
commercial insurance companies claimed that
underwriting health care protection was im-
possible.
Over the years, however, physicians who gave
countless hours of their valuable time, without
remuneration, have been able to put Blue Shield
on a sound actuarial basis.
How does Blue Shield operate?
First, Blue Shield is community oriented,
serving the entire community — not just those
who are the most healthy or are the most profit-
able to enroll. All Plans are non-profit corpora-
tions for community service.
The physicians — who provide the medical
service — have a voice in directing the policies
of Blue Shield and comprise the majority on the
boards of trustees of most local Plans as well as
of the National Association of Blue Shield
Plans.
Blue Shield’s most unique principle is that of
physician participation. Participating phys-
icians originally were, and in theory still are,
guaranteeing the adequacy of Blue Shield re-
serves with their services.
A second phase of participation is the service
concept. In this, the majority of physicians in a
community voluntarily agree to cooperate by
accepting the Plan’s payment as full payment
for their professional services to patients with
certain incomes. The Blue Shield Plans which
do not offer paid-in-full contracts must demon-
strate that their payments are equal to the
average fees charged 75 percent of the patients
in their areas.
Thus, the participating physician plays an ex-
tremely active role in the entire Blue Shield
program — especially in determining policy and
setting payment levels.
Blue Shield has pioneered in the field of med-
ical care prepayment in this country — because
the medical profession stood behind it.
For Blue Shield to continue to serve both the
public and the medical profession, it must con-
tinue to enjoy the support of the entire medical
team.
— 49 —
POST MORTEM
One thing, at least, is apparent from the re-
cent elections: The American people are not
completely sold on the Great Society. It is im-
possible to know exactly which programs of the
89th Congress were so decidedly repugnant to
the current majority, but it is not difficult to
know where the dissatisfaction of the medical
profession lies.
For the Medicare Bill did not become a good,
effective, workable solution to the problems of
medical care for the aged or any other group
simply by becoming a law. The reservations,
inconsistencies, inequities and false assumptions
that were in the context of the bill before it be-
came a law are still there. The problems have
merely been multiplied by the fact that we as
physicians are now duty-bound, for the sake of
our patients and our own skins, to try to under-
stand if possible, precisely what the law does
— and does not — require of us. We need to
know all of the implications of all of the pro-
visions of this law and how they will affect our
relationship with all of our patients, not only
those who are covered by Medicare, but also
those who are not.
Certainly we must obey the law, but this is
only possible if we understand the law, and
that, Doctor, is not easy. There are many sec-
tions of the law that are inscrutable — so vague
and ambiguous that only time and court de-
cisions will ever clarify them. There are other
aspects, such as Title 19 that are broadly per-
missive, and will require state action to imple-
ment them. We will have to be alert to the
activities in our own State House before we
will know whether or not we can accept their
interpretation. Other aspects of the law are
clear enough but are complex and impractical.
One aspect is very clear and very specific and
it should be carefully noted. There is no clause
or provision in the law which compels the phys-
ician to participate in any phase. The physician
is not legally bound to fill out any forms, to
accept payments from any source, to perform
any function which he does not consider to be
in the best interest of his patients. There is, in
fact, only one aspect of the law that is com-
pulsory, and that is the compulsion to pay the
taxes involved.
Without a doubt, it would be easier for us
to fill out in triplicate any and all forms placed
upon our desks by hospitals, patients, and wel-
fare agencies. It would be less troublesome to
meekly accept whatever directives Washington
may send down in the next few weeks or
months. We could just drift along through
trial and error until the situation becomes acute.
In the short run it would save a lot of bother.
But in the long run it will mean the end of the
free practice of medicine.
If you doubt that possibility, look again at
Title 19 of the Medicare Law. Try to logically
deduce the inevitable outcome of the implemen-
tation of that provision in all fifty states, par-
ticularly if all states define medical indigency
as generously as New York State has already
done, and as generously as South Dakota pro-
poses to do. There is no way this plan could
possibly function without complete Federal con-
trol of all expenditures. Your fees will be the
first to feel the purge. Federal agents (who
may or may not know anything about medicine)
will decide which drugs you can administer,
which procedures you can use, and which pa-
tients you can hospitalize for how long. Whether
you like it or not, you will be an agent of the
Federal Government.
Does anyone really think that this is the con-
cept the American people bought when they
accepted the Medicare Law? Of course it isn’t.
— 50 —
JANUARY 1967
They bought a pretty package with a nice little
label. They had no idea what was in the pack-
age. The tragedy is, their doctors didn’t know
either.
Bill G. Church, M.D.
OUR STATE JOURNAL
Reflections for the New Year
The South Dakota Journal of Medicine was
established in January 1948 by John C. Foster
I and Dr. Roland G. Mayer to afford the doctors
of South Dakota an opportunity to record their
scientific work, to express their opinions and
to serve as a media for dissemination of news
and meetings. This venture was considered
quite bold at the time. The membership was
urged to support the project with the publica-
tion of the interesting cases, newsworthy events
and editorials. This policy has been maintained;
there has been increased participation of the
membership in these objectives; this participa-
tion is welcomed and urged.
Following the congressional drug investi-
gations advertising fell to an all time low and
the very existence of the Journal was jeopar-
dized. Mr. Dick Erickson met and has nicely
handled this problem. Our advertising is now
at an all time high.
Your support of the Journal, in patronizing
the advertisers, in submitting your publications,
editorials and news, is the most vital factor in
insuring continued growth. Your help is needed
and we urge your participation in this New
Year.
Robert E. Van Demark, M.D.
LETTER TO THE EDITOR
November 21, 1966
Richard C. Erickson
Executive Secretary
S. D. Medical Association
711 North Lake Avenue
Sioux Falls, South Dakota
Dear Mr. Erickson:
We have received the check of $50.00 for the
Committee on Careers. Thank you very much
for your generous contribution.
May God bless you.
Sincerely,
Sister M. Colette, Treasurer
South Dakota League for Nursing
DOCTOR, DO YOUR PATIENTS
UNDERSTAND YOUR FEES?
Patients hesitate to ask about fees. But they
want to know. They naturally worry about
what their medical costs will be. And if they
don’t feel free to talk about it, serious problems
— misunderstanding, resentment and even deep
hostility — can arise, threatening the all-
important rapport between you and your pa-
tients.
Open discussion before treatment prevents
such embarrassing problems. It paves the way
for mutual understanding and good will.
An AMA Fee Plaque, prominently displayed
in your waiting room, serves as an open invita-
tion for your patients to discuss medical costs
and financial problems with you. It shows that
you care. Just seeing the message can give
many financially worried patients peace of
mind.
The AMA Fee Plaque works hard to prevent
doctor-patient misunderstandings. And it works
well.
How do you obtain one?
Just mail the coupon below and your check,
or money order, for $1.25 (postage paid) to:
Order Department, American Medical Associa-
tion, 535 North Dearborn Street, Chicago,
Illinois 60610. Your Fee Plaque will be sent to
you by return mail.
Order Department
American Medical Association
535 North Dearborn Street
Chicago, Illinois 60610
Please send me A.M.A. fee plaques, offered
at only $1.25 each. Enclosed is my check or money
order for $
Name
Address
City State Zip Code
— 51 —
S.D.J.O.M. JANUARY 1967 - ADV.
Buy Bonds where you work.
They do.
Over 90% of the 101st Airborne Division’s 1st Brigade has
signed up for U.S. Savings Bonds through the Payroll Savings
Plan. That’s what their Minute Man flag signifies. These men,
now in Vietnam, deserve your support. When you purchase
Savings Bonds regularly, you show the men of the 1st Brigade
you’re with them. And you walk a bit taller.
Buy U. S. Savings Bonds
m
The U.S. Government does not pay for this advertisement. It is presented as a public
service in cooperation with the Treasury Department and the Advertising Council.
“fkU U ifcur
MEDICAL ASSOCIATION
News Notes • Changes • Births • News
Pop's Proverb
How great the abyss be-
tween education and in-
telligence.
D. L. Scheller, M.D., Arling-
ton, recently discussed LSD
and other narcotics at a meet-
ing of the Arlington PTA.
❖ ❖ ❖
A program on Auscultation
of the Heart, Phonocardio-
graphy and Pulse Tracings
will be offered by the Institute
for Cardiovascular Diseases at
Good Samaritan Hospital,
Phoenix, Arizona on April 6th
and 7th, 1967. This is an of-
ficial Post-Graduate Course of
the American College of Car-
diology. For information,
write to William D. Nelligan,
Executive Director, American
College of Cardiology, 9650
Rockeville Pike, Washington,
D. C. 20015.
❖ ❖ ❖
The USD Cleft Palate Team
held a clinic at the Crippled
Children’s Hospital and School
in Sioux Falls on January 5th.
Additional clinical sessions
have been scheduled as fol-
lows:
May 4, 1967 — Rapid City,
South Dakota.
June, 1967 — University of
South Dakota, Vermillion.
The Watertown District So-
ciety met on December 6th,
at which time P. Preston
Brogdon, M.D., made his presi-
dential visitation. Officers of
the Society elected during the
meeting include E. H. Hein-
richs, M.D., President; A. K.
Brevik, M.D., Vice president;
T. J. Wrage, M.D., Secretary-
Treasurer; G. E. Tracy, M.D.,
and R. Auskaps, M.D., Dele-
gates; C. J. Clark, M.D., and
D. N. Fedt, M.D., Alternate
Delegates.
❖ ❖ ❖
Isaiah R. Salladay, M.D.,
Pierre, left December 1st for a
60-day voluntary tour of duty
in Viet Nam. This is Dr. Salla-
day’s second tour of service in
Viet Nam.
YOUR
CONTRIBUTION
TO THE
SOUTH DAKOTA
MEDICAL SCHOOL
ENDOWMENT
FUND
IS NEEDED
John T. Elston, M.D., Pen-
nington County Board of
Health chairman, agreed re-
cently to accept the position
of county health officer until
a permanent appointment can
be made. The position has
been handled temporarily by
Dr. Elston since the resigna-
tion of N. R. Whitney, M.D.
❖ ❖ ❖
Robert Giebink, M.D., Sioux
Falls, has offered to donate
land as a site for a new Min-
nehaha County juvenile de-
tention home. Dr. Giebink has
also donated land for the Ad-
justment Training Center,
which, when completed, is de-
signed to assist mentally re-
tarded individuals to become
useful citizens.
^ ^ ^
ANNOUNCEMENT
A continuation course in
“Clinical Electroencephalo-
graphy” will be conducted on
June 5-7, 1967 in Philadelphia,
Pennsylvania. This is the sec-
ond course sponsored by the
American EEG Society (aided
by a grant from the Bureau of
State Services, U.S.P.H.S.) and
is designed for physicians
who have had little or no
formal EEG training. In-
quiries about further details
of the course and registration
procedure should be addressed
to Dr. Donald W. Klass, EEG
Course Director, Mayo Clinic,
Rochester, Minnesota.
— 53 —
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THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
Volume XX February, 1967 Number 2
CONTENTS
Facial Scars 19
John L Terry, M.D.
Clinicopathological Conference — Sioux Valley Hospital 25
John F. Barlow, M.D.; Robert E. Van Demark, M.D.
PathCAPsule 30
Treatment of Hypertension with Combination Therapy 43
William R. Taylor, M.D.
Deadwood Doctor 46
This Is Your Medical Association 50
Second Class Postage Paid at Sioux Falls, South Dakota
Published monthly by the South Dakota Medical Association, Publication Office
711 North Lake Avenue. Sioux Falls, South Dakota 57104
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V 2 °/o jelly for children and adults
1% solution for adults (resistant cases)
Also NTZ® Solution or Spray
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THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
SUBSCRIPTION $2.00 PER YEAR SINGLE COPY 20c
Volume XX February, 1967 Number 2
STAFF
Editor
, Robert Van Demark, M.D.
Sioux Falls, S.
D.
Assistant Editor
.Judith Perkins Schlosser
Sioux Falls, S.
D.
Associate Editor
Robert Thompson, M.D.
Yankton, S.
D.
Associate Editor
Gordon Paulson. M.D.
Rapid City, S.
D.
Associate Editor .
Gerald Tracy, M.D.
Watertown, S.
D.
Business Manager
Richard C. Erickson
Sioux Falls, S.
D.
R. E. Van Demark, M.D., Chr.
EDITORIAL COMMITTEE
Sioux Falls, S.
D.
J. A. Anderson, M.D.
... Madison, S.
D.
G. E. Tracy, M.D.
... Watertown, S.
D.
W. R. J. Kilpatrick, M.D.
.. Huron, S.
D.
Hugo Andre, M.D.
Vermillion, S.
D.
H. B. Munson, M.D
Rapid City, S.
D.
R. F. Thompson, M.D. .. ... ....
Yankton, S.
D.
John B. Gregg, M.D.
Sioux Falls, S.
D.
PUBLICATIONS COMMITTEE
R. E. Van Demark, M.D., Gordon Paulson, M.D., Robert Thompson, M.D., W. T. Sweeney,
M.D.
OFFICERS
South Dakota Stale Medical Association
President P. Preston Brogdon, M.D.
President-Elect John Stransky, M.D.
Vice-President J. T. Elston, M.D.
Secretary -Treasurer A. P. Reding, M.D.
Executive Secretary Richard C. Erickson
Delegate to A.M.A. A. P. Reding, M.D
Alternate Delegate to A.M.A. R. H. Quinn, M.D.
Chairman Council .. E. T. Lietzke, M.D
Speaker of The House J. P. Steele, M.D
Sioux Valley Medical Association
President
Secretary
T reasurer
C. J. McDonald, M.D.
Daniel Youngblade, M.D.
.Karl Wegner, M.D
Mitchell, S. D.
..Watertown, S. D.
Rapid City, S. D.
Marion, S. D.
Sioux Falls, S. D.
Marion, S. D.
Sioux Falls, S. D.
Beresford, S. D.
Yankton, S. D.
Sioux Falls, S. D.
. Sioux City, Iowa
Sioux Falls, S. D.
FACIAL SCARS
John L. Terry, M.D.
1100 Morse Road
Columbus, Ohio 43224
The objective of scar revision is the correc-
tion of wound defects such as depressed, raised,
uneven, widened, hypertrophied, contracted or
pigmented scars. This is achieved by excision
of the offending scar and coaptation of the
wound edges to provide minimal disfigurement.
A great multiplicity of techniques have been
proposed to obtain these results, many of which
are not in accord with the basic concepts of
tissue repair.
In 1947 Straatsma6 stated that “surgical per-
fection per se is not the complete answer to ob-
taining fine scars.” This concept was furthered
by Covarrubias3’ 4 in 1954 when he demon-
strated improved scars by changing the direc-
tion of the excised scar. Multiple interdigitating
triangular flaps oriented in the direction of the
skin tension lines were used to achieve this im-
provement. In 1959 Borges1- 2 reported his ex-
periences using the above technique and coined
the phrase “W” plasty. Other authors have ex-
pressed the opinion that ultra techniques of
repair offer little advantage for their accom-
plishments are obliterated by the process of
wound repair. The above authors have alluded
to the importance of redirecting the course of
the altered scar so its components more nearly
parallel the predominant expression lines.
The present feeling regarding scar revision is
one of attempting to redirect the course of mal-
aligned scars so they more nearly coincide with
the direction of the skin cleavage planes in the
area. In addition to directional re-alignment,
one must use the fundamental techniques of a
traumatic tissue manipulation during the sur-
gical procedure followed by a rigid program of
post operative wound management.
The first question to be resolved is when is it
necessary to change the direction of a scar in
question. This is indicated when the course of
the scar and the skin lines are at variance with
one another. The corollary of the above state-
ment is to say that it is unwise to perform any
of the following redirection maneuvers when
the scar exactly falls in the correct skin line
plane. In fact, it is rather unusual to be called
upon to revise a scar that follows a wound that
has occurred in the direction of the skin lines,
providing the original defect was properly
closed.
Generally speaking, wounds that occur per-
pendicular to the plane of the underlying mus-
culature will coincide with the dominant skin
lines in the area because the contracture of the
muscle causes a shortening of the overlying skin
and therefore produces the characteristic skin
lines. It then becomes obvious that the two
edges of such a scar are literally held together
that occurs parallel to the underlying mus-
culature in the area. On the contrary, a wound
that occurs parallel to the underlying mus-
culature will produce a scar whose length will
be shortened by muscle activity. A newly
formed scar is a semi-rigid structure and it is
believed, at least from the clinical standpoint,
that the longitudinal shortening produced by
muscle contracture is accompanied by trans-
verse widening. An analogous situation could
be produced by placing a cigar-shaped piece of
putty in a vise and closing the vise for a short
distance.
If the above mechanism of formation of un-
acceptable scars is correct, then the manage-
ment of such scars by simple excision and
closure will probably fail to produce the desired
results because the basic biomechanics of the
wound remain the same. The best known way
to relieve the scar from the adverse effects of
the underlying parallel muscle activity is to
change the direction of the scar so that it more
Figure 1
Wounds resulting in scars running parallel to the
underlying musculature usually produce unsatisfac-
tory scars due to end-to-end forces being applied to
the scar. The linear compression tends to produce
widening of the scar in the lateral plane. Revision of
such scars is most successful if the direction of the
scar is changed by breaking up of the original scar
into a series of segments, whose individual axis lie
more parallel to the resting skin lines in the area.
A “W” plasty excision and closure is one method of
change of scar direction.
nearly parallels the skin lines in the area (fig. 1).
Changing the course of the scar may be done
either through the use of a “Z” plasty (fig. 2) or
a “W” plasty. The “Z” plasty is the older of the
two procedures by one hundred years, having
been first described by Denonvilliers5 in 1856.
Figure 2a
Deep facial wound following an automobile accident.
SOUTH DAKOTA
Figure 2b
Depressed scars lying over and parallel to the zygo-
maticus musculature. Note shadows produced by
oblique light. ,
Figure 2c
Multiple “Z” plasties used to change the direction of
the scar. Two large “Z” plasties were used on each
side of the face.
— 20 —
FEBRUARY 1967
The application of the “Z” plasty to any one
scar situation requires more planning than the
use of the “W” plasty in that the former may be
used as a single large “Z” or as multiple smaller
figures, both of which will alter the direction of
the scar, although the former will produce
greater scar lengthening. When planning the re-
lease of a webbed burn scar contracture in-
volving a joint, a single large “Z” is preferred,
while when applied to the redirecting of a facial
scar, multiple smaller components are usually
most desirable.
The “Z” plasty has an advantage in that there
is very little normal tissue discarded, while the
“W” plasty requires that a small amount of
normal skin be excised from either side of the
mark in question. The “W” plasty has the ad-
vantage of being the most simple to apply to
any one scar defect because of the routine
fashion with which it is planned (fig. 3). Regard-
less of which of the two above maneuvers is
Figure 3a
Transverse scars of the cheek as a result of an auto-
mobile accident. Notice width of the defect believed to
have been produced in part because the scar overlies
and parallels the buccinator musculature of the cheek.
The swelling is due to a parotid duct injury, which
was later fistulized into the mouth surgically.
Figure 3b
Following resolution of the parotid problem and the
facial induration, the scar was excised and closed
using the “W” plasty technique. This is the appear-
ance of the wound on the seventh post-operative day.
Note the use of fine monofilament suture material.
One half of the sutures had been removed before this
picture was taken. Splinting adhesive strips were
worn for three weeks after suture removal.
Figure 3c
Result three months post “W” plasty.
chosen for any one scar revision, either will
change the direction of the defect and thus re-
lieve the lateral expansion forces that seem to
be placed on a healing wound that parallels the
musculature of that area. The breaking up of
a single mal-directed scar into a series of
smaller, although connected, daughter segments
forms a zigzag defect, which latter defect can
act as an accordion as the underlying muscle
action tends to shorten it end to end. The ap-
parent accordion-like activity of such a revised
scar seems to better dissipate the heretofore
lateral expansive forces and thus alleviate the
tendency for wide scar formation.
The surgical techniques used in scar revision
are so basic as to hardly deserve mention. Plan-
ning the proposed procedure using some mark-
ing ink, such as Bonnie blue, will often prevent
a series of incisions from being made in the
wrong direction. Suitable skin edges for repair
— 21 —
SOUTH DAKOTA
are made by holding the knife at right angles to
the skin when making incisions. Complete re-
moval of all superficial and deep scar tissue
with accurate hemostasis and tissue re-approx-
imation is important. Dead space should be
avoided in the wound to discourage hematoma
formation and fine gauge non-reactive suture
material should be used to prevent excessive
granuloma and wound reactivity. It is im-
portant that the skin edges be widely under-
mined to reduce wound tension during the acute
healing phase. Wound tension should also be
lessened by the application of a suitable dress-
ing.
The choice of a suitable suture material is an
important facet in the management of un-
acceptable scars. Fine white silk, usually 00000,
is used to tie bleeding points and to re-
approximate the deeper layers of the wound,
such as the facial musculature and the sub-
cutaneous tissues. In situations where there is
much tension on the wound edges, the use of a
fairly heavy (26 to 28 gauge) stainless steel
monofilament wire in the deeper layers of the
dermis is a very useful adjunct. This technique
has the advantage of allowing the suture ma-
terial to remain in the wound for prolonged
periods (two to four weeks) before its removal
becomes necessary (figs. 4a-4d). This prolonged
period of suture retention allows the wound to
more firmly knit before being subjected to the
various forces that characterize the area in
question. The period of wound rest may be
augmented to some degree by the application
of some form of adhesive plaster to the skin
to lessen the intensity of traction (wound
separating) forces to which the suture line may
be subjected. Dressings per se will be dis-
cussed later.
Fine nylon suture is preferred for the skin
closure proper in most instances. This material
is a monofilament with a smooth surface and is
almost inert in the tissues. True allergic re-
actions to nylon must be rare and it does not
tend to conduct surface moisture into the depths
of the wound. The smooth surface mitigates
against the introduction of bacteria into the
tissues at the time of suturing and its removal
is probably less painful because of the polished
exterior. Nylon skin sutures may be left in situ
for prolonged periods without production of
significant tissue reaction and they tend to be
less reactive when subjected to exposure to
saliva or nasal secretions. The author prefers
this material also because the tension on the
wound can be adjusted by slipping the second
knot, even when a true square knot is employed.
The above listed qualities for this material
should not be taken as grounds for discarding all
the other synthetic suture materials now avail-
able, because the great majority of them possess
the same qualities to a greater or lesser degree.
Timing of suture removal is not felt to be a
critical issue if a proper dressing is applied, if
the sutures are tied so as to just approximate
the wound edges and if one of the new synthetic
strands is used. This is because of the lack
of tissue reaction to these substances. If the
wound has been adequately splinted by the
dressing, it is customary to leave face-skin su-
tures in place from five to seven days, although
eyelid sutures may be removed in three to five
days. Very fine plain absorbable suture has been
used in the eyelids of children to diminish the
psychic trauma to all concerned at the time of
“suture removal.” Granted, the wound may be
somewhat more reactive for several weeks, but
this reactivity usually subsides without sequella.
Figure 4a
Post-automobile accident laceration in a 21 year old
dental assistant. The wound edges were excised prior
to closure.
— 22 —
FEBRUARY 1967
Figure 4b
The subcutaneous tissues have been closed with fine
absorbable suture material. A twenty-eight gauge
stainless steel wire has been used intra-dermally for
skin closure.
Figure 4c
“Butterflies” are used to help splint the wound after
the removal of the initial operative dressing which
had been left in place for one week. The wire suture
was removed after the third week.
A proper dressing should allow any wound
discharge to be excreted and easily absorbed.
The dressing should not adhere unduly to the
sutures and make dressing changes difficult.
All these properties can be achieved by using
Figure 4d
Result at six months after the injury.
a narrow strip of Adaptic (R) gauze (preferably
impregnated with Furacin Topical Cream (R)
to facilitate the adherence of the Adaptic to
the suture line until the remainder of the dress-
ing can be applied), covered by an equally nar-
row strip of cotton gauze (as cut from the heel
of a “four by four”). The entire wound peri-
phery is then painted with Tincture of Benzoin
and multiple strips of one half inch adhesive are
then laid over the narrow gauze strips while the
two wound edges are gently held together.
If this latter step is done correctly, all lateral
tension is removed from the wound and the
sutures placed then have only to hold the wound
edges in the correct vertical relations. From
seven to ten layers of adhesive should be used
so as to form a plaque over the incision, which
plaque-like mechanism prevents outside forces
from disturbing the healing wound. The patient
should be encouraged to refrain from excessive
facial motion such as chewing, talking, laugh-
ing, et cetera. This dressing should be left un-
disturbed for about one week, after which time
the sutures can be removed, but the wound
— 23 —
SOUTH DAKOTA
should be resplinted for an additional two to
four weeks using either a formal adhesive dress-
ing or “butterflies.” After this time the area
should then be massaged gently with some
bland lanolin bearing cream, such as Nivea (R),
until the reactivity subsides, which is usually
two to five months. There may be a beneficial
effect from having the patient take some form
of citrus fruit daily, so as to insure sufficient
ascorbic acid for normal wound maturation.
There are both local and systemic factors that
may impede healing, and therefore predispose
to the formation of excessive scar deposition.
Uremia, uncontrolled diabetes, anemia, hypo-
proteinemia and scurvy are examples of sys-
temic wound healing deterrents, while necrotic
tissue, foreign bodies, dead space, hematoma
and excessive mobility are some of the local fac-
tors that interfere with normal repair.
SUMMARY
1. Wounds that occur parallel to the normal
skin lines seldom require re-operation, pro-
viding the edges were properly sutured
initially.
2. Wounds occurring parallel to the underlying
musculature, and therefore perpendicular to
the skin lines in the area, should be revised
not only using atraumatic surgical technique
with fine suture material, but should be
broken up into a series of connected segments
whose individual axis no longer parallel the
underlying musculature.
3. A dressing applied to reduce wound tension
and mobility along with prolonged post op-
erative splinting are important.
4. Both systemic and local factors influence
wound repair.
BIBLIOGRAPHY
1. Borges, A.: La W-plastia en la tratamiento de las
cicatrices. Rev. Latino- Am. Cirurg. Plast., 4:10,
1959.
2. Borges, A. F.: Improvement of antitension-lines
scar by the “W-plastic” operation. Brit. J. Plast.
Surg. 12:1, 1959.
3. Covarrubias, A. R. VII Congreso Latino- Americano
de Cirugia Plastica, October, 1954.
4. Covarrubias, A. R.: In Borges, A., “Cirugia Plastica
de una Herida Cutanea,” Rev. Confed. med. pan-
amer., 5:1, 1958.
5. Denonvilliers, M.: Blepharoplastia. Bull. Soc. Chir.
de Paris. 7:243, 1856-1857.
6. Straatsma, C. R.: Surgical technique helpful in
obtaining fine scars. Plast. & Reconstr. Surg., 2:21,
1947.
He leaves to make
an urgent call
But doesn’t use
the phone at all
Parepectolin for quick relief of acute diarrhea
...soothes colicky pain with paregoric
...consolidates fluid stools with pectin
...adsorbs irritants with kaolin, and protects
intestinal mucosa
Whether it’s a 24-hour “bug”, a food problem,
or simply nervousness and anxiety, Parepectolin
will bring the diarrhea under control until etiol-
ogy can be determined. In some cases, Parepec-
Each fluid ounce of creamy white suspension contains:
Paregoric (equivalent) (1.0 dram) 3.7 ml.
Contains opium (% grain) 15 mg. per fluid
ounce.
warning : may be habit forming
Pectin (2% grains) 162 mg.
Kaolin (specially purified) .... (85 grains) 5.5 Gm.
(alcohol 0.69%)
Usual Adult Dose: One or two tablespoonfuls three
times daily.
WILLIAM H. RORER, INC.
Fort Washington, Pa.
24 —
CLINICOPATHOLOdrlCAL CONFERENCE - SIOUX VALLEY HOSPITAL
From the Intern and Resident Teaching Conferences of the Sioux Valley Hospital, Sioux Falls
JOHN F. BARLOW, M.D.*
Pathologist — Editor
ROBERT E. VAN DEMARK, M.D.**
M.S. ( Orth. Surg.)
Orthopedic Surgeon — Discusser
This 16-year old Caucasian female was re-
ferred for pain in the left knee of three months’
duration.
The pain was worse on motion, especially on
running or stopping. She had no fever or joint
swelling and no pain in other joints. There was
no weakness, weight loss or other generalized
symptoms.
Past medical history and review of systems
was not contributory. Family history was nega-
tive for bone disease or malignancy.
Physical examination revealed a well-
developed, well-nourished white female in no
distress. Vital signs were normal. Examination
of head, neck, chest, and abdomen was un-
remarkable. Neurologic examination was nega-
tive.
There was a small area of tenderness on the
lateral aspect of the left knee just superior to
the joint in the area of the lateral femoral con-
dyle. There was a suggestion of a prominence
in the area. There was good range of motion in
the knee and no other tenderness or accumula-
tion of fluid.
Hemogram showed hemoglobin of 12.6 gms%,
hematocrit of 39 vol%, WBC 10,400/mm3 with
63% segmented neutrophils, 1% neutrophils, 4%
eosinophils, 1% basophils, 30% lymphocytes,
and 1% monocytes. Urinalysis revealed slightly
turbid dark yellow urine with pH 6.0, specific
gravity 1.025 and 1+ protein. There was no
sugar. Sediment showed 4-7 WBC, rare RBC
and some squamous cells and bacteria. Serum
calcium and phosphorus were within normal
limits.
X-rays showed a lytic lesion of distal left
lateral femoral condyle.
An operation was performed on the second
hospital day.
CLINICAL DISCUSSION
Dr. Robert E. Van Demark: In summary we
have a 16-year old white female who has pain
^Lecturer in Pathology, School of Medicine, Univer-
sity of South Dakota.
**Professor of Orthopedic Surgery, School of Med-
icine, University of South Dakota.
over her left lateral femoral condyle. There is
no evidence or clinical history suggestive of in-
volvement of the adjacent joint or systemic
symptoms of any kind. I wonder if Dr. Breit
would like to discuss the x-rays.
Dr. Donald H. Breit*: You can easily see this
lesion of the lateral side of the lower femur ex-
tending into the condyle and across the meta-
physis into the distal diaphyseal region (Fig. 1).
I don’t see any associated soft tissue change;
the margins are fairly distinct in that region.
There is slight suggestion that there may be a
little loculation but it’s not very definite. We
should be first interested in whether it is a
primary or secondary lesion. It is, of course,
Figure I
Eccentric osteolytic defect at epiphyseal region in dis-
tal femur.
* Radiologist, Sioux Valley Hospital.
— 25 —
SOUTH DAKOTA
most unlikely to be secondary since the patient
is only 16 and the location would be unusual for
a metastasis. The location, however, does not
completely rule out a metastatic lesion since
metastases may occur in any part of any bone.
I think the lesion is most likely a primary
benign bone tumor. A few years ago I would
have probably rather quickly called this a giant
cell tumor but more recently there has been so
much controversy over giant cell tumors I am
beginning to wonder if such an entity exists.
There have been six or more new lesions of
bone with giant cells described since 1942 and
this could be any one of them. There is either
bone destruction or these could be principally
cartilage elements that we see. Also this might
represent a developmental arrest such as fibrous
dysplasia or a hamartoma. It has some of the
characteristics of a solitary cyst but the location
is against it. They are more usual in the dia-
physes. We most commonly see them in the
distal femur, proximal tibia, proximal humerus
or distal radius. This patient had pain in the leg
so there was some activity in the lesion within
the past two or three months. There is no evi-
dence of a pathological fracture. If this were
a fibrous dysplasia or hamartoma there wouldn’t
be any reason for pain unless there had been a
pathological fracture which could occur from
the weakness of the bone caused by destruction
in the area.
Dr. Van Demark: Thank you, Dr. Breit. The x-
ray shows a lytic lesion of the lateral femoral
condyle that appears to involve primarily epi-
physis with extension into the metaphyseal area.
It is eccentrically located. There is no surround-
ing sclerosis of bone and there is no periosteal
reaction. The outer cortex of the bone is not
involved. A differential diagnosis then funda-
mentally involves those tumors and tumor-like
lesions peculiar to the ends of the medullary
cavity of long bones and not primarily of the
cortex.
As Dr. Breit mentioned, I think it an excellent
possibility that this case is a giant cell tumor
despite the fact that the patient is only in her
second decade. The highest incidence of giant
cell tumors is in the third decade. The eccen-
trically placed lytic lesion is rather charac-
teristic of a giant cell tumor particularly when
it appears to involve primarily the epiphysis as
it does here. There are both benign and
malignant giant cell tumors. Certainly on these
x-rays there is no evidence of malignancy. How-
ever, we have to remember that even in some
giant cell tumors which have metastasized the
histology and x-ray picture appear benign.
I would be remiss if I did not mention in ad-
dition to a giant cell tumor, a benign chondro-
blastoma, sometimes known as a “Codman’s
tumor.” About 80% of these occur in the sec-
ond decade. This usually shows a distinct mar-
gin of sclerosis about the edge of the lesion.
It involves the epiphyseal area primarily and
may show calcification within the tumor.
The third lesion that I would consider is that
of a chondromyxoid fibroma. About 80% of
these occur in patients under 30. Most of them
primarily involve the metaphysis but occasion-
ally they involve both metaphysis and epiphysis
as we see in this case. If treated by curettement
alone they have a tendency to recur even if they
are not malignant. In these cases it is advisable
to excise as much adjacent normal bone as
possible.
Another lesion which should always be men-
tioned in any patient in his second decade is a
unicameral bone cyst. This can be ruled out
with certainty here because a bone cyst always
occurs in the metaphyses or down in the shaft
and does not involve the epiphysis as we have
here.
Another lesion that one has to consider in a
medullary lesion is an enchondroma of bone.
Enchondromas of long tubular bones are rather
rare; they occur most frequently in the hands
and in the feet. In the long tubular bones the
enchondroma usually involves the metaphyseal
or distal shaft area and shows patchy calcifica-
tion in a central area of rarefaction. We cer-
tainly don’t have such a picture here. An en-
chondroma in a long tubular bone tends to be-
come malignant as the patient grows older in
contrast to enchondromas of the short bones of
the hands and feet where they are practically
always benign.
This brings us to the subject of possible malig-
nancy. There are two lesions to consider in this
category. First, metastatic disease as Dr. Breit
has mentioned always has to be considered in
any lytic lesion of bone. However, this girl has
no evidence of metastatic bone disease else-
where and it would be very unusual to have so
large a lesion present as a metastasis without
evidence of a primary tumor elsewhere. I do re-
member one lytic lesion in a patella which
turned out to be the only metastatic lesion that
could be found in a carcinoma of the cervix. It
is important to keep metastatic disease in the
back of your mind in the differential diagnosis
of lytic lesions.
— 26 —
FEBRUARY 1967
The second type of malignant lesion to con-
sider in a destructive lesion of a medullary
cavity is a central fibrosarcoma. It’s rare and
occurs in older individuals. Its aggressiveness
depends on its histopathology. An anaplastic
lesion often breaks through bone and invades
soft tissue. I don’t think this lesion is a central
fibrosarcoma.
From the standpoint of non-neoplastic tumor-
like lesions the orthopedic surgeon has always
to think of his old friend hematogenous osteo-
myelitis which mimics other osteolytic lesions.
This occurs in the epiphyseal or metaphyseal
area but there is a little different x-ray picture
with it. There is an area of surrounding bone
sclerosis which we don’t have in this case. Also
if there is a large focus of osteomyelitis there
are marked systemic symptoms accompanying
it.
There is one other lesion that is rarely en-
countered and that is cystic tuberculosis which
does occur in the epiphysis. It is usually a
smaller lesion with a tendency to invade the ad-
jacent joint. We do not have such findings here.
This is a large lesion without evidence of joint
involvement either clinically or otherwise. I’m
going to list these lesions that I have mentioned:
DIFFERENTIAL DIAGNOSIS
Neoplastic (Benign)
1. Giant cell tumor
2. Benign chondroblastoma
3. Chondromyxoid fibroma
4. Unicameral bone cyst
5. Enchondroma
Neoplastic (Malignant)
1. Metastatic bone lesion
2. Central fibrosarcoma
Tumor-Like Lesions
1. Hematogenous osteomyelitis
2. Cystic tuberculosis
This also could always be one of the many
very rare lesions of bone. For example, I have
had a desmoplastic fibroma of bone which is
difficult to differentiate from a low grade fibro-
sarcoma. However, we have followed the lesion
ten years and it is benign.
To return to the lesions we have mentioned
earlier, we know this case is not cystic tuber-
culosis because it is too large and there is no
involvement of the joint or systemic symptoms.
Hematogenous osteomyelitis is unlikely in the
absence of systemic symptoms and surrounding
bone sclerosis. The patient is not in the age
group for central fibrosarcoma and the x-ray
picture is not suggestive of that lesion. There
is no evidence for primary malignancy nor are
there other lytic lesions of bone to suggest a
metastasis.
Enchondromas of long tubular bones are rare
and there is no calcification. Unicameral bone
cysts occur more toward the center of the bone
in the metaphyseal and shaft regions. Now if I
were going to the races, I would put the odds
on the horses as 60% for giant cell tumor, 30%
for benign chrondroblastoma and 10% for
chondromyxoid fibroma. I don’t think I can
lose, (laughter)
Dr. Barlow: Would the patient’s personal phys-
ician care to comment?
Dr. Robert R. Giebink*: My associate, Dr. H.
Phil Gross, and I took care of this patient. She
was a normal, healthy young lady and there was
no sign of any serious illness except the lesion
in the knee. The differential diagnosis is cer-
tainly very complete. I might mention a few re-
mote possibilities: What about Gaucher’s disease
or one of the reticuloendothelioses? They are
pretty rare in the epiphyses aren’t they?
Dr. Van Demark: They occur mostly in the shaft.
Dr. Giebink: Another lesion in this age group
is eosinophilic granuloma which occurs mostly
in the membranous bones, ribs, or clavicle. I
suppose they could occur in this location.
Dr. Van Demark: When present in a long bone
they also occur primarily in the shaft.
Dr. Giebink: Our own differential diagnosis in
this case was principally between a giant cell
tumor and chondroblastoma. We did not con-
sider a chondromyxoid fibroma very seriously.
Dr. Richard D. Schulizt: I would like to ask
about the possibility of a metaphyseal fibrous
defect or its related lesion, a non-ossifying
fibroma.
Dr. Van Demark: Non-ossifying fibroma or
metaphyseal fibrous defect occurs in the meta-
physis and does not involve the epiphysis pri-
marily.
PATHOLOGIC DISCUSSION
Dr. Barlow: Your betting odds at the turnstile
of this clinicopathologic horse race were well-
chosen. At surgery this was a solid vascular
lesion which was curetted and the cavity filled
with bone chips. Histologically the lesion is a
benign giant cell tumor composed of an abund-
ant cellular stroma with scattered giant cells
(Figs. 2-3). The giant cells are multinucleated
with nuclei similar to those of the stromal cells.
Note that the stromal cells are very plump and
mitoses are not infrequent.
* Orthopedic Surgeon, Sioux Valley Hospital,
t Pathologist, Sioux Valley Hospital.
— 27 —
SOUTH DAKOTA
Figure II
Many multinucleated giant cells with intervening
plump stromal cells.
Figure III
Higher power to show characteristic stromal cells,
one in mitosis (arrow).
As mentioned by Dr. Breit, many lesions of
bone contain giant cells which in themselves
are not diagnostic. In fact, every lesion men-
tioned in Dr. Van Demark’s differential diag-
nosis may contain a variable number of giant
cells. The important point in the diagnosis is
to study carefully the stromal cells. In giant cell
tumor these are plump with mitoses and the
nuclei of the stromal cells are similar to those
in the giant cells.
One of my professors of pathology used to say
that if you take away the giant cells and there
is still tumor, the lesion is a giant cell tumor.
If you take away the giant cells and just fi-
broblasts and hemorrhage are left, you are deal-
ing with some other lesion such as brown tumor
of hyperparathyroidism or one of the other
lesions mentioned by Dr. Van Demark.
I would also like to emphasize the importance
of the pathologist obtaining an accurate clinical
history from the orthopedic surgeon in addition
to a radiologic interpretation from the radio-
logist before attempting to diagnose any lesion
of the bone. Histology alone is not sufficient to
differentiate among many bone lesions.
I have reviewed several large series of giant
cell tumors from the literature. Several points
should be stressed: (1) It used to be thought that
a giant cell tumor under the age of 20 was a
rare lesion but in the series of Hutter et al2
19.9% of the cases were below 20 while 77' '{ of
them occurred between the ages of 20 and 49.
(2) The lesions of the jaw containing giant
cells should be excluded from the discussion of
giant cell tumor. The jaw lesions are benign
and rarely recur. They are better referred to
as giant cell reparative granulomas. With the
exclusion of these, most giant cell tumors occur
in the distal femur, proximal tibia and distal
radius. They may, of course, less commonly
occur in virtually any bone.
(3) If the lesions of the jaw are excluded giant
cell tumor becomes a much more aggressive
disease. Well over 50% of the cases in many
series will exhibit at least one recurrence and
up to 30% may recur more than once before
cure. The recurrences that are cured are usually
(81%) within the first two years.
(4) About 10-30% of giant cell tumors may be
malignant according to Hutter et al and Mur-
phy and Ackerman.4 The malignant change
may be present in the first biopsy specimen
or may develop over several years. In the
above series of 76 cases 23 were malignant, 8
of which were malignant on the first biopsy,
7 showed malignant changes developing in
benign lesions over 1-5 years, and 8 showed
malignant changes developing after 5 years in
an originally benign lesion.
(5) Marked variation in cellular and nuclear
features of the stromal cells is the most accurate
criterion for the histological assessment of
malignancy in giant cell tumor. The giant cells
are usually fewer and have fewer nuclei. Areas
of cartilage or osteoid are also features of a
malignant giant cell tumor. However, even so-
called “benign” giant cell tumors have been
known to metastasize. As indicated, benign
giant cell tumor of bone is an aggressive lesion
with a high recurrence rate and a definite pre-
dilection for malignant change.
Dr. Richard J. Weaver*: Dr. Van Demark, didn’t
you report a recurrent giant cell tumor at one of
our previous clinicopathologic conferences?
* Pathologist, Sioux Valley Hospital.
— 28 —
FEBRUARY 1967
Hasn’t there also been a recent paper from the
Mayo Clinic recommending more radical sur-
gery for these lesions?
Dr. Van Demark: About a year and one-half ago
we reported in this journal6 a recurrent giant
cell tumor at the lower end of the radius. In that
case we excised the end of the radius and re-
placed it with a graft from the fibula. This pa-
tient was in the office recently and I took out
one of the screws placed at the time of surgery.
She is doing very well and has a normal appear-
ing wrist and hand which she uses quite func-
tionally. We are protecting it with a brace until
the fibular transplant becomes entirely well-
vascularized but I think it’s going to be an
excellent result. This is a case which had re-
curred once following curettement. That brings
up the second point about the recurrence rate in
giant cell tumors. The present trend is toward
more radical excision if technically feasible
primarily because of the high recurrence rate. I
believe Dr. Weaver has in mind the publication
of Dr. Dahlin in which he reports a recurrence
rate more than 50%. 1 Because of the high re-
currence rate with curettage, the surgeons at
the Mayo Clinic have come to regard this
method less favorably. I am entirely in agree-
ment with the treatment given in this case and
I think I’d do exactly as Dr. Giebink did. I be-
lieve the treatment was good and I believe in
the lower end of the femur this is the treatment
of choice.
Dr. Giebink: Dr. Gross and I have had several
giant cell tumors in the past three years. We
believe the initial treatment should be curette-
ment and replacement by bone chips. If there is
recurrence the surgeon is then presented with
the difficult problem of deciding what to do
next — replacement as Dr. Van Demark did,
repeat curettement, or radiation. We have had
one giant cell tumor in a metacarpal which re-
curred twice but has not recurred for 2-3 years
now after the third curettement.
Sometimes radiation may be effective in these
lesions. Dr. Breit may want to comment on this.
However, I feel that if you are going to curette
the lesion you should leave the radiation for
later. If the lesion recurs I favor trying to re-
place as much of the whole bone as technically
feasible.
Dr. Van Demark: I agree. When I first practiced
orthopedic surgery, radiation was used for quite
a few of these lesions. In my experience it has
often given quite satisfactory results. Often 3
to 4 weeks after irradiation of a giant cell tumor,
the lesion will appear to have turned malignant
but it will usually then go on to recalcify. The
point is not to become discouraged too easily if
the lesion appears to be progressing soon after
irradiation. ’ , " ,
Dr. Breit: In the past we have treated several
giant cell tumors by irradiation with success. In
general I do not recommend it as the treatment
of choice. However, there may be a place for
radiotherapy in giant cell tumor, particularly
the malignant ones.
BIBLIOGRAPHY
1. Dahlin, D. C.; Bone Tumors, Charles C. Thomas,
Springfield, 111., 1957, page 73.
2. Hutter, R. V. P. et al; Benign and Malignant Giant
Cell Tumors of Bone, Cancer, July 15, 1962.
3. Mnaymneh, et al; Giant Cell Tumor of Bone, Jour-
nal of Bone and Joint Surgery, Jan., 1964.
4. Murphy, R., and Ackerman, L. V.; Benign and
Malignant Giant Cell Tumors of Bone, Cancer,
1956.
5. Cohen, D. M., et al; Vertebral Giant Cell Tumor
and Variants, Cancer, 1964.
6. Van Demark, R. E., and Bloemendaal, R. D.; Re-
current Giant Cell Tumor of Radius, South Dakota
Journal of Medicine, Vol. 18, July, 1965, pp. 18-20.
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— 29 —
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Submitted by the College of American Pathology in
connection with the South Dakota Society of Pathol-
ogists.
THE SIMPLE
LABORATORY TEST
Is there a simple laboratory test?
If so, it must be rare. Certainly many tests
may seem simple if the observer or the person
working at the bench is ignorant of all of the
pitfalls that accompany every manipulation.
As an example, let’s explore hemoglobin de-
terminations. This has been a frequently per-
formed analysis since Gowers introduced the
first method in 1878. The number of papers
written on the subject since that time is as-
tronomical. Yet just what is the present status
of performance of this commonest of all tests?
In 1963 a total of 398 laboratories returned re-
sults of their analyses of a hemoglobin solution. 1
Iron analyses of the sample yielded a calculated
value of 15.9 Gm. of hemoglobin per 100 ml. of
blood. The mean value of the returns was 15.7
Gms. Only two-thirds of the reporting labora-
tories obtained values between 14.9 Gm. and
16.5 Gm. Values as low as 10.5 Gm. and as high
as 18.6 Gm. per 100 ml. were reported. In view
of this, even though it looks simple to see a
technician perform a single dilution and read
the result from a scale on a photometer, it would
certainly be erroneous to imply that determina-
tion of hemoglobin is a simple test.
An advertisement for Bromsulphalein (BSP)
uses the provocative phrase “and is an ex-
tremely simple test to perform.” This extremely
simple test has resulted in a number of deaths.
After eleven years experience with admin-
istering the dye it appeared to this writer that
such reactions always occurred elsewhere.
Amidst complacency two severe reactions were
encountered following its use in one month.
After such experiences would not the phrase
“potentially dangerous test” seem more appro-
priate? According to Dr. McGath2 who has
supervised over 200,000 of these tests, it is not
a simple one.
Some of the potential traps in performing
simple tests might be elusive to the most
sagacious chemist. Even the method of trans-
portation of the specimen to the laboratory is
hazardous. The quickest way is not always the
best. For example, pneumatic tube transpor-
tation of blood interferes with determinations
of hemoglobin, serum LDH, and serum potas-
sium.3 The simple hematocrit is markedly al-
tered when it is determined on blood taken from
a vacuum tube which has been only partially
filled.
What about the many “dip sticks”? In some
instances, the various ribald comments over-
heard in the laboratory seem appropriate. In a
recently published article numerous problems
resulting from the estimation of blood urea
nitrogen by a currently popular “simple test”
are pointed out.4 Indeed, a paradox exists
when on one hand knowledge and instrumen-
tation have shown such rapid and spectacular
advances and on the other tests are offered
which give imprecise and even misleading re-
sults. Moreover, hospital administrators and
practicing physicians could be misled into the
idea that the well appointed laboratory consists
of a bag of variegated bits of paper.
If such problems are encountered in the
“simple tests” the more complicated tests can
be traumatic indeed for the technologist, and
most hazardous to the physician and his pa-
tient. “It is high time to stop misleading the
public and the physician about laboratory tests.
None is simple and certainly none is extremely
simple. They are all involved, complicated, and
full of pitfalls and possible inaccuracies clear
down to the written report on the patient’s his-
tory. It takes a clear appreciation of these many
possible errors and a long period of training and
experience in order to master laboratory pro-
cedures to an acceptable level.”2
The responsibility for maintaining good
clinical laboratories, of necessity, resides within
the medical profession. Pathologists are clearly
those most responsible; however, the full un-
derstanding and cooperation of all medical
groups are essential to maintaining excellent
laboratory medicine standards. Indeed, it is
just as important to send the patient, the pa-
tient’s blood, or other biological sample to a
properly supervised laboratory as it is for the
patient to see a properly trained physician in
the first place.
REFERENCES
1. Sunderman, F. W., Am. J. Clin. Path. 43:9. 1965.
2. McGath, T. B., Am. J. Clin. Path. 39:630, 1963.
3. McClellan, E. K., et al. Am. J. Clin. Path. 42:152.
1964.
4. Logan, J. E., Canad. M.A.J. 89:341, 1963.
— 30 —
FEBRUARY 1967
DEFINITIVE
SYPHILIS SEROLOGY
In 1907, Wassermann modified the comple-
ment-fixation test of Bordet to detect syphilis
antibody, or reagin, in the serum of infected
humans.1 Since that time a large number of
complement-fixation procedures have been de-
veloped. Of these the Eagle and Kolmer tests
are still in use. With the discovery that an
alcohol-soluble lipid from beef heart served
equally as well, Wassermann’s original antigen,
extracted from syphilitic livers, was no longer
used. A second group of tests has been de-
veloped that use a particulate cardiolipin an-
tigen and are flocculation rather than comple-
ment-fixation tests. Among these are the Hin-
ton. Kline, and VDRL tests. The VDRL is most
widely used, particularly as a screening test for
syphilis.
Following the early application of serologic
tests for syphilis it became apparent that a
certain percentage of sera gave “biologic false-
positive” reactions. These reactions occur fol-
lowing a number of febrile illnesses and im-
munizations, notably smallpox vaccination, and
are usually transient. Persistent biologic false-
positive reactions with cardiolipin antigen are
found in chronic degenerative diseases and may
sometimes be more important than a true posi-
tive reaction, for example in dysproteinemia and
lupus. Occasionally even the sera of normal
healthy individuals will give a false positive
reaction. For this reason, before a positive test
result is accepted it should be confirmed with a
different type of reaction. Since the antigen
employed in most tests is cardiolipin, these tests
differ only in sensitivity rather than specificity
and the problem of false positive reactions is not
always resolved. This is particularly obvious
when the same serum is tested by two methods
with varying results or when positive reactions
are not compatible with the history and phys-
ical findings.
The Reiter Protein Complement Fixation test
(RPCF)3 has the virtue of marked increased
specificity due to the use of an antigen that is
treponemal in origin. This increased specificity
is effective in ruling out many false-positive
reactions. Some problems of sensitivity with
the test, however, have been encountered.
With the introduction of the Treponema pal-
lidum Immobilization test (TPI), Nelson2 was
able to demonstrate the difference between the
true syphilis antibody and reagin responsible
for false-positive reactions. This great increase
in specificity for syphilis antibody is due to the
use of a strain of Treponema pallidum as test
antigen instead of cardiolipin. The TPI test in-
volves the use of motile treponemes recently ex-
tracted from infected rabbit testes. The organ-
isms can be seen to lose their motility when
syphilis antibody and complement are added
to the preparation. This is a microscopic deter-
mination. Complement with normal serum does
not affect motility. This test, although tech-
nically difficult, is accurate to a marked degree.
The Fluorescent Treponemal Antibody test
(FTA) is another method for testing serum for
syphilis antibody.3 The antigen is essentially
the same as that used in the TPI although the
treponemes are not alive at the time of testing.
In this procedure, the serum under test is added
to previously fixed smears of T. pallidum. Dur-
ing incubation, syphilis antibody from positive
serum will coat the treponemes. The presence
of this antibody is determined by counter-
staining the slide with fluorescein-labeled anti-
human globulin. When examined microscopic-
ally, using a darkfield condenser and strong
ultra-violet light source, positive slides are seen
to contain brilliantly fluorescing treponemes.
Slides made with negative serum contain tre-
ponemes that do not fluoresce and are difficult
to visualize.
Both the TPI and FTA tests are specific for
syphilis antibody. They are equally accurate
in distinguishing false-positive reactions to car-
diolipin antigen. Neither is suited for routine
screening for syphilis.
Because the TPI test requires a constant
course of infected rabbits to supply the viable
antigen, it has not been found suitable for the
average serology laboratory. The FTA test is
more frequently used because of lesser technical
difficulties and availability of commercially
prepared reagents.
For a routine screening procedure for syphilis
the VDRL and other flocculation tests are ade-
quate when reactive sera are confirmed by
any of the more sensitive complement-fixation
tests. When biologic false-positive reactions are
suspected or when results of two different tests
are not consistent, definitive serological pro-
cedures are indicated. Because of its increased
availability, the FTA test is more frequently
used. REFERENCES
1. Dubos, R. J.: Bacterial and Mycotic Diseases of
Man 3rd. Ed., the J. B. Lippincott Company, 1958,
Philadelphia, p. 527.
2. Nelson, R. A. and Mayer, M. M. J. Exper. Med.,
89:369, 1949.
3. U. S. Department of Health, Education, and Wel-
fare, Serologic Tests for Syphilis, 1964 Manual.
— 31 —
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AREA CODE 605 TELEPHONE 336-3480
7TH & PHILLIPS, SIOUX FALLS, S. D. 57102
. . . the piace to yo por
j ij our f^rintina needi
l9
TREATMENT OF HYPERTENSION
WITH
COMBINATION THERAPY*
William R. Taylor. M.D.
422 Fifth Avenue S.E.
Aberdeen. South Dakota
Since the advent of the thiazides in 1958 they
have attained a position as the basic therapy for
many forms of hypertension. The dominant ac-
tion of hydrochlorothiazide is to increase the
excretion of sodium and chloride and an ac-
companying volume of water through inhibition
of tubular reabsorption. This decrease in plasma
volume plus the peripheral vasodilatation which
occurs with long term use of the thiazides ac-
counts for its reduction of blood pressure.
Hydrochlorothiazide alone is not always ade-
quate to control the hypertension and it there-
fore has frequently been used in combination
with other drugs. Ganglionic blocking agents
have often been used in the past; however,
since guanethidine has been available (Feb-
ruary, 1959), the blocking agents have been used
less and less frequently. Guanethidine lowers
blood pressure by inhibiting sympathetic vaso-
* A six months study of Esimil in the treatment of
hypertension in thirteen patients in the moderately
severe group.
motor tone without interfering with parasym-
pathetic function, resulting in fewer side effects
than are obtained with ganglionic blocking
agents. For moderately severe forms of hyper-
tension which have not responded to the thiazide
drugs alone it has been common practice to em-
ploy hydrochlorothiazide and guanethidine in
separate tablets. Combined therapy allows
effective use of smaller doses of the more
powerful agents, and therefore reduces the in-
cidence and severity of side effects. Average
reductions in pressure induced by the different
agents are approximately additive when they
are combined.
Because of the desire to simplify the patient’s
medical regime, to decrease the possibility of
missed doses of medication, and to decrease the
over-all expense to the patient for his long term
and usually continual medical therapy, a com-
bination of hydrochlorothiazide, 25 mgs., and
guanethidine, 10 mgs., was made available for
experimental use in June, 1965.
— 43 —
SOUTH DAKOTA
Between June and December, 1965, thirteen
patients were evaluated on this combination,
called Esimil* by its manufacturer. No patient
was put on the drug who had had a satisfactory
or excellent response to his or her prior anti-
hypertensive therapy, consequently the patients
were either newly diagnosed and had had no
prior therapy, or their response to their prior
therapy had been less than adequate. The only
other selection of patients was the fact that it
was necessary for them to be seen at least every
two weeks in the office for evaluation of their
blood pressure in the sitting, supine and stand-
ing positions and for indicated laboratory tests.
The patients’ ages ranged from 42 to 76 years.
Eight of the patients were male and five were
female. Nine of the thirteen patients had essen-
tial hypertension. One had chronic bilateral
renal disease with bilateral nephrolithiasis.
Three patients had previously had one kidney
removed for reasons other than hypertension.
One of the latter was a 76-year old woman, an-
other a 57-year old male and the third, a 45-year
old woman.
* Esimil was supplied by CIBA Pharmaceutical Com-
pany, Summit, New Jersey.
Therapy was initiated with from one to two
tablets daily depending on the severity of the
patient’s hypertension and the type of therapy
having been employed prior to institution of
Esimil therapy. No adverse reactions developed
while shifting from their prior therapy to
Esimil. Six had been on no prior therapy; two
had been on rauwolfia preparations alone; one
took a combination of Aldomet, Hydrodiuril,
Ismelin and Apresoline in high dosage; another
took Inversine, 10 mgs. q.i.d.with Hydrodiuril,
100 mgs. daily and a third had been on Apre-
soline, 200 mgs. daily and hydrochlorothiazide,
100 mgs. daily. Control had been inadequate in
all instances in which medical therapy was
being employed at the time of change to Esimil
therapy.
Refer to Table #1 for patient information.
The response to Esimil therapy was classified
as excellent in four of the nine with essential
hypertension indicating that the blood pressures
had fallen to acceptable and/or normal range
with moderate and well tolerated doses of the
medication. One who was classified as a good re-
sponse at the end of the six months’ study had
obtained an excellent response during the sub-
TABLE I
Pt.
%
Age
in
Yrs.
Sex
HBP
Known
Yrs.
Complications
Previous Therapy
BP before Rx
Supine Erect
1
57
M
9
arteriosclerosis obliterans;
iliac saddle thrombus;
Positive Masters
none
208/110
160/110
2
52
M
1
none
Hydrodiuril
160/110
158/120
3
60
F
15
none
Inversine; Hydrodiuril
Ismelin
220/110
210/130
4
42
M
1
none
none
150/110
140/104
5
68
M
8
none
Apresoline; Hydrodiuril
160/106
130/104
6
49
F
1
none
none
200/100
214/120
7
67
M
10
none
none
170/110
194/120
8
55
M
1
bilateral nephrolithiasis
none
150/100
140/90
9
45
F
5
right nephrectomy
Aldomet; Hydrodiuril;
Ismelin; Apresoline
202/120
180/100
10
70
M
6
cerebral thrombosis
Sandril
180/80
170/80
11
57
M
2
cerebral thrombosis;
left nephrectomy
Hydrodiuril
200/110
170/100
12
68
F
3
diabetes
none
200/90
170/100
13
76
F
12
unilateral renal disease;
probable nephrosclerosis
Raudixin
244/110
230/110
— 44 —
FEBRUARY 1967
: sequent two months. One patient’s response
was classified as good and one as fair. The drug
was discontinued in two instances in those with
essential hypertension because of nausea and
vomiting in one instance and vertigo in the
second. The response of the blood pressure had
been fair in a 45-year old male in whom nausea
and vomiting had necessitated discontinuation
of the drug and excellent in the elderly woman
in whom vertigo was prominent, and in whom
postural hypotension developed. One patient
who had not previously been on therapy and
who had chronic nephrolithiasis had an excel-
lent response to Esimil. Two of the patients with
one surgically absent kidney had a fair response
and the third a good response to Esimil. Dosage
of the drug ranged from one to six tablets daily
or from 10 mgs. of guanethidine with 25 mgs. of
hydrochlorothiazide to 60 mgs. guanethidine
with 150 mgs. of hydrochlorothiazide.
In summary, the efficacy of employing hydro-
chlorothiazide and guanethidine in treatment of
various forms of hypertension has been well
proven and the combination of these two drugs
in one tablet would seem to be a logical and
advantageous addition to the armamentarium of
the physician treating moderately severe to
severe hypertension on an out-patient basis.
REFERENCES
1. Vertes, V., Sopher, M., Clinical Studies on Hydro-
chlorothiazide Antihypertensive and Metabolic
Effects, JAMA 170: 1271-1273 (July) 1959.
2. Bryant, J. M., Schvartz, N., Roque, M., Fletcher,
L., Fertig, H., Lauler, D. P., The Hypotensive
Effects of Chlorothiazide and Hydrochlorothiazide,
Amer. J. Cardio: 392-395 (March) 1961.
3. VA Corporation Study on Antihypertensive Agents,
Double Blind Control Study of Antihypertensive
Agents, Arch. Int. Med. 110: 222-236 (August) 1962.
4. Stevenson, M., Goodman, N., Finkelstein, D.. Bellet,
S., The Effect of Guanethidine in the Treatment
of Hypertension, Amer. J. Cardio 7: (3) 386-391
(March) 1961.
5. Eagan, J. T., Orgain, E. S., A study of 38 Patients
and Their Responses to Guanethidine, JAMA 175:
550-553 (February) 1961.
6. Ford, R. V., Treatment of Hypertension with
Guanethidine and Hydrochlorothiazide, Geriatrics
16: 577-580 (November) 1961.
7. Kelly, J. J., Housel, E. L., Daly, J. W., Clinical
Experience with Guanethidine in the Treatment of
Hypertension JAMA 176: 577-580 (May) 1961.
8. Chandrasekar, R. J., Coppo, J. O., Duane. G. W.,
Pierre, G., Thurmann, M., Utley, J. H., Janney,
J. G., Clinical Evaluation of Guanethidine Sulfate,
a New Antihypertensive Agent, Amer. Heart J. 63:
(3) 309-319 (March) 1962.
9. Brest, A. N., Moyer, J. H., Newer Approaches to
Antihypertensive Therapy, JAMA 172: 1041-1044
(March) 1960.
Tabs
Esimil
Daily
Init. Final
Wks.
Rx
BP after Rx
Supine Erect
Side Effects
Results and Comments
1
3
20
170/90
140/80
none
E — continues on Esimil
discontinued Rx after
1
6*
24
146/110
130/100
nausea & vomiting
F — mos. because of nausea
vomiting
1
6
16
230/130
160/100
heartburn
F — continues on Esimil
1
2
8
138/80
130/90
none
E — continues on Esimil
1
4
12
170/110
140/100
diarrhea
F — continues on Esimil
1
5
20
180/104
140/80
vertigo, heartburn
G — continues on Esimil
1
4
24
168/100
160/100
none
G — continues on Esimil
1
1
8
140/98
132/90
none
E — continues on Esimil
2
3
24
180/114
170/110
diarrhea if Esimil
over 3 tabs daily
F — added Apresoline; con-
tinues Esimil
1
1
8
150/90
130/80
none
E — continues on Esimil
2
2
12
164/104
168/118
none
F — continues on Esimil
1
0*
12
150/100
150/90
vertigo
discontinued Rx after
F — wks. because of vertigo
1
2
8
180/80
146/80
slight vertigo
G — continues on Esimil
* discontinued therapy
— 45
SOUTH DAKOTA
DEADWOOD DOCTOR
F. S. Howe, M.D.
CHAPTER VIII
Horses and Autos
All the practice of medicine in those days was
done by horse, with horse and buggy or team
and buggy. After I had been here for some time,
I got the mining contract to take care of the
Dakota Mining Company employees. The mill
was in Deadwood and the mine was at Trojan.
John Hunter was general manager and later my
father-in-law. He had a mine manager who was
very partial to a couple of doctors in Terry and
he wanted Mr. Hunter to switch to one of the
other doctors. I used to ride horseback to Tro-
jan, 11 miles each way. One day I was up in
the forenoon in January and in the early eve-
ning this mine manager called me to come up
and see his daughter, which made a total of 44
miles horseback just for that one contract. I
went up there and asked where the sick girl was
and what was the matter. She said that she had
a headache, so I gave her a few aspirin tablets.
I looked at the thermometer. It was 27 below.
Many, many times I rode horseback to Trojan
twice a day when it was way below zero. The
mine manager labored under the delusion that if
he made it tough enough for me that I would
quit; but in spite of the fact that I had to make
two trips a day on many days, sometimes to
treat fake headaches, he didn’t know me very
well. I stuck. He lost his job.
I believe the hardest trip I ever made was to
what was known as Spearfish Cyanide. This
mill and mine was situated about 8 miles be-
yond Trojan. The mine manager called me in
the early evening and said that he had a very
sick woman and asked me if I could come out.
I told him if I could get a team, sleigh and
driver, I would come, although there was a big
storm raging.
I got the team and driver and we started out
at 7 p.m. We had to go by way of Lead and
Terry and after we got just a little way out of
Lead we found that we were traveling up the
railroad track instead of the highway. When
we arrived at the foot of Trojan hill, there was
an immense drift. The sleigh turned over and
dumped us and all of our paraphernalia out in
the snow. We had a quiet team, however, and
we got everything back in and proceeded on our
way. When we got to Trojan where the wind
really had a chance, we could not see the road.
We could only see an outline of the horses and
it appeared that we might have to turn back.
The only guide we had was the telephone poles.
We solved this, however, by having the driver
get out and walk ahead, then call. I would drive
up to where he was again. We did this until we
got to Crown Hill. From there, the road was
protected by timber and it was not so difficult to
follow. We finally arrived at 3 o’clock in the
morning, 8 hours of the hardest kind of travel-
ing to get 18 miles. I found that the sick woman
had danced all night the night before and wasn’t
so desperately ill as the mine manager thought.
We stayed until 6 o’clock. The storm had quieted
down and we had no trouble making the day-
light trip. Three or four hours after we left
there, we were back in Deadwood. We were
gone about 14 or 15 hours. I found that Dr. Bow-
man, who had a fine team and was very familiar
with every road in the entire territory, had
started in the afternoon, turned around, given
up and came home.
It had been my custom to make night trips
alone with team and buggy, believing that the
team would follow the highway. Sometime
during the early fall of the year 1909, I was
called out to a little mining camp near Galena
one night and due to high water in the spring
every bridge had been washed out — I think
there were some fourteen bridges. I had my own
horse and hired a livery horse to fill in. About
2 or 3 o’clock in the morning I was on my way
home and as usual trusting the horses to follow
the road when suddenly the livery horse dis-
appeared from sight. I found that the horse had
stepped right off the bank into a deep pool,
taking the buggy and my horse with him. For
some reason the buggy did not turn over. At
first I heard wild plunging and kicking, then
silence. I knew what that meant — that the
horse was under water and would be drowned.
I made a long jump out of the buggy and landed
in water probably three or four feet deep, pulled
the horse’s head out of the water and tried to
get him up but failed. I then let go of the horse’s
head, rushed back and got one trace loose then
another trip to the horse’s head to give him
some air. A flying trip back to get the other
trace loose, then after much urging I finally
got the horse up on his feet, pulled the buggy
out, tied the team to a tree and headed back for
the place where I had made the sick call. I
borrowed a lantern and some clothing from the
man — believe me, that water was cold. He
came out and helped me get started. The rest
of the trip was uneventful, but that was the last
time that I ever made a night trip alone.
46 —
FEBRUARY 1967
There were two other trips that were interest-
ing. One was a night trip to a farm three miles
below the town of Whitewood on an obstetric
case. While we had cars at this time, they were
not too dependable and I hired a livery team
and driver. When we left Deadwood shortly
after midnight, the thermometer registered 27
below zero. We wrapped up in fur coats, hot
bricks to our feet but were in the usual open
buggy. When we struck the prairie country
about 6 miles from Deadwood, we had a terrific
: head-on wind. We faced this for about 7 or 8
miles. When we finally got to the house which
had a light which I assumed was the right one,
little did we care whether it was the right one
or not. We drove into the yard and stopped.
We were both so cold that we were unable to
get out of the buggy. We called. A couple of
men came out of the house, assisted us out of
the buggy and into the house. This proved to
be the right place and as was very often the
case, the baby arrived before I did. We re-
mained for an hour or two getting thawed out
and then started for home. With the wind at
our backs, we had no trouble going home; in
fact, did not suffer from the cold.
On one trip which was also a confinement
case made during the month of January, I used
four methods of transportation on the 21 mile
trip. I first started out in my car with Dick
Costello, the police chief, as driver. After we
had made about 12 miles, we got completely
hung up in the snow. We started to shovel, and
it seemed almost a hopeless job to shovel out.
I left Dick Costello in charge of the car with
i the hope that he would be able to get out and
started walking with my heavy satchel toward
' the section house at Dumont. After I had
walked about a mile, some boys came along with
a team and sled. To say that I was glad to see
them expresses it very mildly. I hopped into the
sled and they very quickly took me to the sec-
tion house. There the Burlington section boss
got out his motor car and after fixing a canopy
to protect us from the cold wind, we proceeded
6 miles to Nahant. Just when we left the section
house, I looked at the thermometer. It was 32
degrees below zero. We made the trip down to
Nahant without any difficulty and much to my
disgust I found that it was a false alarm. I told
these folks that so far as I was concerned, they
would either bring the patient to the hospital
or get another doctor, that I had made my last
trip out there. They had hailed from Iowa and
they proceeded to tell me how the Iowa doctors
made these trips. I told them that they were
now in South Dakota and that if they wanted
my services they would have to come in to the
hospital. Strange to say, the baby was born
about a week later and they did get another
doctor to go out. At that time the weather was
not so severe. The roads were plowed out and
I understand that the trip was made without
incident.
The transition from horseback to team and
then from team and buggy to automobile, was
to say the least, very interesting. My first car
was a 1911 Model T Ford which I purchased in
the summer of 1911. A carload of Model T’s
came in on the Burlington Railroad and were
unloaded at the freight depot in Deadwood.
I had secured a Ford instruction book and
knew it from cover to cover. The only thing I
lacked was I didn’t know what a carburetor
was or whether it was in the rear axle or in the
engine. I didn’t know what a transmission was
or where it was, but I had carefully studied the
instruction book. I was in the same fix: that
the embryo surgeon is when he studies in a text-
book, how to do an appendectomy but has never
done one or seen one.
After the cars were all unloaded, the Ford
dealer said, “These cars are all shipped with
draft attached. If you will give me your check,
I will appreciate it.” I wrote out my check
and handed it to him. We put some gasoline in
the car, and he said he would spend a week
showing me how to drive the car. He told me
that I wouldn’t have any trouble, so we got in
the car. He told he to take the wheel and drive.
He showed me what to do and we went down
the street together coming along fine.
When we got down opposite the First National
Bank, the dealer said, “Would you mind stop-
ping here? I want to run in with these checks
to deposit them. I’ll be right back out. You
just wait for me.” I waited very patiently but
so far as I know he is still in the bank. I never
saw him again.
The question then was what I should do. I
knew nothing about backing up. I didn’t know
how much room to take to turn the car around.
I solved this by driving down to the lower end
of town and going around the race track. I
got home safely but had many thrilling and in-
teresting experiences learning to drive the
Model T. After one year of the Model T in which
one didn’t have power enough to negotiate most
of our mountain roads, I thought I wanted a big-
ger car. My next car was a Mitchell, which of
course had an entirely different shift than the
old Model T. I naturally had plenty of trouble
— 47 —
SOUTH DAKOTA
getting myself adjusted to the new shift. At that
time one of the famous cars was the Lozier 6
made in Detroit. About 1916, I purchased a
Lozier 6, seven passenger car. This was at the
time considered one of the best cars in this
territory. Their only rival was a White Steamer.
We arranged a road race to Sundance, Wyoming,
50 miles away, and after thousands of dollars
were up on the race, the owner of the White
Steamer backed out and returned the money.
I used the Lozier car for a number of years. I
got fine service out of it.
Among other trips that we made in this car
was our first trip to Yellowstone National Park.
At that time, we had five children, one of them
a baby about a year and a half old. We started
out with seven in our family and another man
for a relief driver, together with a girl friend
of the family. The relief driver was supposed to
be, according to his own words, an expert driver,
but after I turned the wheel over to him and let
him drive for about half a block, I took the
wheel over and did all the rest of the driving.
We went by way of Miles City which was a
mere trail with more than 30 gates to open along
the way. We were told to take our own drinking
water which we did — 2 ten-gallon cans, one on
each fender. We had a fire extinguisher in the
car and our first adventure occurred 10 miles
out of Belle Fourche and about 40 miles from
Deadwood when we had a light shower. I was
going along beautifully when suddenly the car
started out across the prairie and ended up in
a gulley where there was fortunately no water
at the time. I failed to realize that a little rain
on gumbo makes grease.
I put on our chains and backed up. This
time I hit the bridge. The first time I missed it.
After a mile or two we ran out of the rain. We
had intended to make Miles City for our first
night’s stop. As we were going along about 20
miles possibly from the nearest house, a fire
suddenly blazed up clear over the hood. I
jumped out and turned off the gasoline, pro-
ceeded with fire extinguisher and water, finally
getting the fire out. The relief driver started
across the prairie and might be going yet if we
hadn’t got the fire out. This time I decided to
leave the hood up and started out again but
after a few miles the car was again on fire. The
fire was put out without much trouble. I then
cut the ground wires, leaving us without lights
but with no more fires. When we arrived at
Broadus, Montana, I went to a garage but the
garage man said that he was not prepared to
do the electrical work. We were at that time
some 90 miles from Miles City but he said that
we had better have that work done at Miles
City.
We got lost out of Alzada. We went 20 miles
before we found anybody. We finally saw a
sheep herder who told us that we had missed
the turn and had to go back and start over.
The garage man at Broadus told me that there
was a ranch 15 miles away known as the Y-T
Ranch that took in travelers. I did not want to
take chances on driving after dark without
lights so we proceeded to this ranch where we
were well taken care of and had a fine supper
and breakfast.
The following morning we left early for Miles
City. The weather was extremely hot. We
stopped to test our tires when we got to Miles
City and found one with 120 pounds of air. At
Miles City we found a good electrical shop and
had our transmission wires fixed up in excellent
condition. That night we made it to Billings
after a hard hot trip. It was impossible to get
any reservations in the hotels. We finally found
a rooming house without any outside windows,
merely sky lights. We slept very little that
night and in the morning started out for Gard-
ner, the Park entrance. We had to take a de-
tour. Coming down that detour the steering
knuckle came down. Of course, I lost control of
the car but fortunately had good brakes. I was
able to wire it up temporarily and came to a
blacksmith shop where he fixed it up so that
we could get by. We made it to Livingston,
Montana, that night and again looked all over
town for accommodations. The only thing we
could find were some rooms with skylights over
an undertaking establishment. The young lady
who was with us asked the undertaker if any
of the downstairs inhabitants would wake us up
during the night. He said he thought that they
were all very sound sleepers and that they
would not disturb us.
We left Livingston in the early morning and
drove as far as Old Faithful and all the other
geysers. We completed our trip to the Park and
except for the fact that most of the family got
food poisoning, had a fine trip through the Park.
We came out the Cody entrance and returned
the same way through Montana. For some rea-
son, the gates were not so hard to open on the
way back and the trip was uneventful. Gasoline
was then 50 cents a gallon, not only in the Park
but all the way through the inland regions of
Montana. We have made trips to the Park since
but none of them had the thrill of the original
trh?- (To be Continued)
48
Ihti U ifcur
MEDICAL ASSOCIATION
News Notes • Changes • Births • News
Pop's Proverb
Few of us are what the
Divine Plan had us slated
for.
At their recent meeting the
Aberdeen District Medical So-
ciety elected the following
slate of officers:
President
Karlis Zvejnieks, M.D.,
Aberdeen
Vice President
William Taylor, M.D.,
Aberdeen
Secretary-Treasurer
David Seaman, M.D.,
Aberdeen
Delegates
G. J. Bloemendaal, M.D.,
Ipswich
Paul Bunker, M.D.,
Aberdeen
Bernard Gerber, M.D.,
Aberdeen
Alternate Delegates
Samuel Rosa, M.D.,
Redfield
Walter Miller, M.D.,
Aberdeen
George McIntosh, M.D.,
Eureka
The National Methodist Con-
vocation on Medicine and
Theology will be held in
Rochester, Minnesota on April
5-7, 1967. Only advance regis-
trations will be accepted. The
registration fee is $20.00 and is
to accompany your registra-
tion request. Such requests
should be addressed to: Na-
tional Methodist Convocation,
P. O. Box 102, Rochester, Min-
nesota 55901.
YOUR
CONTRIBUTION
TO THE
SOUTH DAKOTA
MEDICAL SCHOOL
ENDOWMENT
FUND
IS NEEDED
At their December 15th
meeting, the Yankton District
Medical Society elected the
following officers.
President
Dagmar Glood, M.D.,
Viborg
Vice President
Alan Domina, M.D.,
Tyndall
Secretary
Larry Savage, M.D.,
Yankton
Treasurer
Morris Radack, M.D.,
Yankton
❖ ❖ ❖
The newly elected officers
of the Seventh District Med-
ical Society are as follows:
President
J. S. Devick, M.D.,
Sioux Falls
Vice President
D. L. Ensberg, M.D.,
Sioux Falls
Secretary
B. J. Begley, M.D.,
Sioux Falls
Treasurer
R. R. Giebink, M.D.,
Sioux Falls
— 49 —
SOUTH DAKOTA
The December 18 th re-
cipient of the Sioux Falls
Argus-Leader's Citizen of the
Week Award was a retired
Sioux Falls physician and
surgeon — L. J. Pankow, M.D.
Doctor Pankow was recently
honored by the staff of Mc-
Kennan Hospital for his long
service to that organization.
In addition, in 1960 he was
awarded the Distinguished
Service Award of the South
Dakota State Medical Associa-
tion.
During his more than 40
years of practice in Sioux
Falls, he filled every elective
office in the South Dakota
State Medical Association and
the 7th District Medical So-
ciety.
For several years he was
chairman of the state group’s
Grievance Committee.
Doctor and Mrs. Pankow
have a daughter, Mrs. Lyndon
M. King, Jr.
Dr. and Mrs. A. W. Spiry of
Mobridge returned recently
from a visit to Quito, Ecuador.
Doctor Spiry had been in-
vited by the Ecuadorian Acad-
emy of Medicine and Society
of Gastro-enterology to teach
and work with specialists in
their field.
Alan K. Brevik, M.D., has
been elected chief of staff of
St. Ann Hospital in Water-
town. Carroll Clark, M.D., is
Vice Chief of Staff and James
Larson, M.D., is Secretary.
* * *
The American Medical As-
sociation has notified the
Executive Office of the fol-
lowing appointments.
Arthur A. Lamperi, M.D.,
Rapid City — reappointed to
a one year term on the Coun-
cil on Legislative Activities of
the AMA.
Arthur P. Reding, M.D.,
Marion — appointed to a one
year term on the Council on
Rural Health of the AMA.
A. P. Peeke, M.D., Volga —
reappointed to a one year term
on the Committee on Medicine
and Religion of the AMA.
^ ^ ^
Robert R. Giebink, M.D.,
was honored on December
11th as the “Citizen of the
Week” by the Sioux Falls
Argus-Leader.
The honor was bestowed in
recognition of Doctor Gie-
bink’s generosity in offering
land as a site for the Minne-
haha County Juvenile De-
tention Home.
Earlier in the year he do-
nated a tract for the Adjust-
ment Training Center in Sioux
Falls.
The Department of Oto-
laryngology of the Illinois
Eye and Ear Infirmary and
the College of Medicine of the
University of Illinois at the
Medical Center, Chicago, will
conduct a postgraduate course
in Laryngology and Bron-
choesophagology from April
10 through 22, 1967. Interested
registrants should write di-
rectly to the Department of
Otolaryngology, College of
Medicine of the University of
Illinois at the Medical Center,
Postoffice Box 6998, Chicago,
Illinois 60680.
The American College of
Physicians announces the
Kansas Regional Meeting,
Kansas City, Kansas, Feb-
ruary 24, 1967. INFO: Sloan
J. Wilson, M.D., University of
Kansas Medical Center, Kan-
sas City, Kan.
^ ^ ^
The South Dakota Division
of the American Cancer So-
ciety advises that they have
five films available for pro-
fessional medical audiences.
These films can be obtained
by contacting the South Da-
kota Division directly at P. O.
Box 865, Watertown.
— 50 —
Additional information available
to the medical profession upon request.
Eli Lilly and Company
Indianapolis, Indiana 46206
700037
1DENTI-CODE™
(formula identification code, Lilly)
provides quick, positive product
identification.
ANNUAL MEETING — SOUTH DAKOTA STATE MEDICAL ASSOCIATION
RAPID CITY, SOUTH DAKOTA JUNE 3, 4, 5, & 6, 1967
when it counts...
Chloromycetin’
(chloramphenicol)
IMMi
■ . -
.
.
.
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In controlling abnormal uter-
ine activity, LUTREXIN, the
non-steroid “uterine relaxing
factor” has been found to be
the drug of choice by many
clinicians.
No side effects have been
reported, even when massive
doses (25 tablets per day) were
administered.
Literature on indications and
dosage available on request.
Supplied in bottles of
twenty-five 3,000 unit tablets.
HYNSON, WESTCOTT & DUNNING, INC.
I
BALTIMORE, MARYLAND 21201
( LTR 2 2 )
in VIVO
measurement of LUTREXIN (Lututrin) on contracting uterine muscle
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
Volume XX March, 1967 Number 3
CONTENTS
Pesticide Poisoning: The Insecticides 25
J. N. Spencer, Ph.D.
Antimicrobial Therapy in Pediatrics 30
James N. Etteldorf, M.D.; Stanley E. Crawford, M.D.
Clinicopathological Conference — Sioux Valley Hospital 37
John F. Barlow, M.D.; Richard S. Hosen, M.D.
PathCAPsule 50
Deadwood Doctor 52
Editorial 55
President’s Page . . 56
This is Your Medical Association 57
Second Class Postage Paid at Sioux Falls, South Dakota
Published monthly by the South Dakota Medical Association, Publication Office
711 North Lake Avenue, Sioux Falls, South Dakota 57104
When the stagnant sinus
must be drained...
In the common cold, Neo-Synephrine is unsur-
passed for reducing nasal turgescence. It stops
the stuffy feeling at once. It opens sinus ostia to
re-establish drainage and lessen the chance of
sinusitis. With Neo-Synephrine, in the concentra-
tions most commonly used, decongestion lasts
long enough for extended breathing comfort,
without endangering delicate respiratory tissue.
Systemic side effects are virtually unknown.
There is little rebound tendency.
Winthrop Laboratories, New York, NY. 10016
Brand of phenylephrine hydrochloride
is available in a variety of forms,
for all ages:
Vb% solution for infants
V4% solution for children and adults
V4% pediatric nasal spray for children
V2 % solution for adults
V2% nasal spray for adults
V2 °/ 0 jelly for children and adults
1 % solution for adults (resistant cases)
Also NTZ® Solution or Spray
Antihistamine-decongestant
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
SUBSCRIPTION $2.00 PER YEAR
SINGLE COPY 20c
Volume XX
March, 1967
Number 3
STAFF
Editor -Robert Van Demark, M.D Sioux Falls, S. D.
Assistant Editor Judith Perkins Schlosser Sioux Falls, S. D.
Associate Editor. Robert Thompson, M.D Yankton, S. D.
Associate Editor Gordon Paulson, M.D. Rapid City, S. D.
Associate Editor Gerald Tracy, M.D. ...Watertown, S. D.
Business Manager Richard C. Erickson Sioux Falls, S. D.
EDITORIAL COMMITTEE
R. E. Van Demark, M.D., Chr.
J. A. Anderson, M.D.
G. E. Tracy, M.D
W. R. J. Kilpatrick, M.D.
Hugo Andre, M.D
H. B. Munson, M.D.
R. F. Thompson, M.D.
John B. Gregg, M.D.
Sioux Falls,
... . Madison,
Watertown,
Huron,
..Vermillion,
Rapid City,
Yankton,
Sioux Falls,
S.
S.
S.
S.
S.
S.
S.
S.
D.
D.
D.
D.
D.
D.
D.
D.
PUBLICATIONS COMMITTEE
R. E. Van Demark, M.D., Gordon Paulson, M.D., Robert Thompson, M.D., W. T. Sweeney,
M.D.
OFFICERS
South Dakota State Medical Association
President
President-Elect
Vice-President
Secretary -T reasurer
Executive Secretary
Delegate to A.M.A.
Alternate Delegate to A.M.A.
Chairman Council
Speaker of The House..
P. Preston Brogdon, M.D. .... Mitchell,
John Stransky, M.D. Watertown,
J. T. Elston, M.D. Rapid City,
A. P. Reding, M.D Marion,
Richard C. Erickson Sioux Falls,
A. P. Reding, M.D Marion,
_R. H. Quinn, M.D Sioux Falls,
E. T. Lietzke, M.D Beresford,
J. P. Steele, M.D Yankton,
s.
D.
s.
D.
s.
D.
s.
D.
s.
D.
s.
D.
s.
D.
s.
D.
s.
D.
Sioux Valley Medical Association
President C. J. McDonald, M.D
Secretary Daniel Youngblade, M.D.
Treasurer Karl Wegner, M.D
Sioux Falls, S. D.
. Sioux City, Iowa
Sioux Falls, S. D.
PESTICIDE POISONING:
THE INSECTICIDES
By
J. N. Spencer, Ph.D.
Director, South Dakota Poison Information Center
and Associate Professor of Pharmacology
University of South Dakota School of Medicine
Vermillion, South Dakota
Fully 20% of the information requests re-
ceived by the South Dakota Poison Informa-
tion Center involve cases of poisoning due to
pesticides.1 Without question, the wide em-
ployment of pesticides is an important factor
> contributing to our high level of agricultural
productivity. On the other hand, there are more
than 200 pesticides on the market, some of
which are as toxic to man as they are to the
pests against which they are employed. Any
one of these pesticides may be sold under a
number of trade names. This, combined with
the diversity of their toxicology and the mul-
; tiplicity of symptoms which they may induce,
can confuse the physician called to diagnose a
case of pesticide poisoning. Even in those cases
where a history of exposure to a specific agent
can be obtained, an antidote may not be avail-
able.
The pesticides most frequently responsible for
the cases of poisoning coming to our attention
are the insecticides. They are the cause of at
least 70% of all of the cases of pesticide poison-
ing occurring in South Dakota.1 The two classes
commonly involved are the organophosphates
and the chlorinated hydrocarbons. The present
survey will be limited to a consideration of some
of the more pertinent points regarding their
toxicology and the methods of treatment of
poisoning produced by them.
The Organophosphale Insecticides
Chemically, this group of insecticides is
closely related to the nerve gases, some of the
most toxic agents known to man. In 1961 they
accounted for approximately 3 percent of the
total U. S. production of pesticides. In the same
year, they were responsible for 54 percent of the
cases of pesticide poisoning occurring in the
state of California.2 Those approved for use in
South Dakota 3 are listed in order of their de-
creasing toxicity in Table I.
TABLE I.
Major Organophosphale Insecticides
Recommended for use in South Dakota
Thimet
EPN
Cygon
Phosdrin
Delnav
Baylex
Deneton
Co-Ral
Dylox
Di-Syston
Ethion
Dibrom
Parathion
Vapona
Ronnel
Guthion
Diazinon
Malathion
The pharmacology of the organophosphate
insecticide has been covered in an extensive re-
view by Holmstedt.4 Their great hazard is the
ease with which they are absorbed through any
body surface. Sprays, vapors or powders may
be absorbed from the conjunctiva, skin or res-
piratory tract; solutions, in addition to being
absorbed through the skin, may be absorbed
from the gastrointestinal tract. Most rapid ab-
sorption is from the respiratory tract.
A portion of the absorbed organophosphate is
hydrolyzed by the tissue phosphorylphos-
phatases. The rate of hydrolysis varies with the
insecticide; the slower the hydrolysis, the
greater the toxicity. The comparatively low
toxicity of malathion may be due in part to its
relatively rapid hydrolysis. The absorbed or-
ganophosphate escaping hydrolysis combines
with various tissue enzymes, rendering them in-
active. Most characteristic of organophosphate
intoxication is the inactivation of the cho-
linesterases; both the pseudocholinesterases of
SOUTH DAKOTA
the plasma and the acetylcholinesterase of the
tissue are affected. This inactivation is a two
stage reaction, a rapid binding of the enzyme at
the esteratic site followed more slowly by a
binding at the anionic site. The initial bond at
the esteratic site may be hydrolyzed, but with
the completion of the bond at the anionic site,
a stable, irreversible organophosphate-
cholinesterase complex is formed. As a result
there is an inhibition of the hydrolysis of ace-
tylcholine by the cholinesterases.
Acetylcholine is involved in neuromuscular
as well as synaptic transmission within the
peripheral and central nervous systems. Essen-
tial to both neuromuscular and synaptic trans-
mission is the rapid hydrolysis by acetylcho-
linesterase of the acetylcholine released during
the transmission process. The accumulation of
acetylcholine resulting from the block of
esterase activity produces an effect comparable
to prolonged and intense stimulation of both the
peripheral and the central nervous system.
In severe acute organophosphate intoxication
there may be a 90% or greater inactivation of
the cholinesterases.5 The symptoms of intoxica-
tion are readily recognizable; pinpoint pupils,
chest pain, laryngospasm, increased secretions
(salivation, lacrimation, sweating, etc.), brady-
cardia, muscular cramps, muscle fasciculations,
general muscular weakness, abdominal cramps,
nausea, vomiting, diarrhea, severe headache and
central nervous system depression. Death, when
it occurs, is probably due to respiratory
paralysis and is commonly preceded by convul-
sions. Fortunately poisoning of such severity is
rare. More common, the symptoms are limited
to abdominal cramps, nausea, and headache or
possibly pinpoint pupils and tightness of the
chest.
Chronic organophosphate intoxication is prob-
ably more common than realized. The stable,
inactive product formed as the result of the
interaction of the insecticide and the cholin-
esterases can only be replaced by the synthesis
of new enzyme. Inactivated acetylcholinesterase
is replaced at the rate of about 1% per day.5
Inactivated pseudocholinesterase may be re-
placed at a somewhat more rapid rate, but 90
days or more may be required to restore the
plasma and tissue cholinesterases to within nor-
mal limits. Consequently short multiple ex-
posures to organophosphates over an extended
period could be expected to be cumulative in
their effects. The slow decrease in esterase ac-
tivity may lead to the development of some de-
gree of tolerance, but ultimately a level of in-
hibition is reached at which overt symptoms
are apparent. Gersham and Shaw6 report 16
such cases of chronic organophosphate poison-
ing, 13 of which involved workers in agricul-
ture. The period of exposure varied from IV2 to
10 years. Of the 16 patients, 5 were diagnosed
as schizophrenics, 7 as depressed, 3 complained
of impaired memory, and 1 of chronic fatigue.
Other symptoms were tremors, ataxia, muscular
weakness, speech difficulties, anxiety, emotional
lability and somnambulism. Total blood cho-
linesterase determinations were obtained on two
of the patients diagnosed as schizophrenic, one
exhibited 50%, the other a 60% reduction in es-
terase activity. On removal of these patients
from exposure, even with treatment, recovery
was slow. Most of the patients, however, had
recovered sufficiently to return to a productive
life within a year.
Cholinesterase determinations are of little
value in acute organophosphate poisoning, but
are of the utmost importance in the diagnoses
and prevention of chronic intoxication. There
is a relatively close correlation between the de-
gree of cholinesterase inhibition, specifically the
inhibition of red blood cell acetylcholinesterase,
and the symptomatology. Workers subjected
chronically to low levels of exposure to the or-
ganophosphates or other insecticides capable of
inhibiting cholinesterase, as sevin, would be
well advised to have plasma and red blood cell
cholinesterase determinations at monthly in-
tervals. As a general rule, for workers on the
ground a 40% to 60% decrease in red blood cell
acetylcholinesterase should be considered a
danger signal, indicating the immediate transfer
of the individual to work in which he would not
be exposed to anticholinesterase agents.7 In
the case of pilots of crop-dusting aircraft, the
degree of depression of acetylcholinesterase that
could be tolerated without impairment of flying
skills would be considerably less. In view of the
neurological deficit noted at low levels of
cholinesterase inhibition by Bower, et al.,8 a de-
crease of 20% probably should be considered a
danger signal necessitating the grounding of the
pilot.
The key to the successful treatment of acute
poisoning with anticholinesterase agents is early
diagnosis and the prompt administration of
atropine and pralidoxime (Protopam Hydro-
chloride). Initially treatment should be directed
toward the establishment of a patent airway
and the relief of any cyanosis present. This
should be followed by large intravenous or
intermuscular doses of atropine. Atropine in
26 —
MARCH 1967
large doses will antagonize the visceral (mus-
carinic) action of acetylcholine, but has little
effect on its neuromuscular blocking (nicotinic)
action. However, there is a direct relationship
between survival and the rapidity and intensity
of atropinization. In the recommended dose of
2 mg, atropine is well tolerated, even in the
presence of mild cholinesterase inhibition. In
severe poisoning this dose should be repeated
every 5 to 10 minutes until the visceral symp-
toms are relieved or signs of atropine over-
dosage (dry, flushed skin and tachycardia) are
apparent. A mild degree of atropinization
should be maintained for at least 24 to 48 hours
after exposure. In severe cases of poisoning 10
to 20 mg of atropine or more may be necessary
to obtain maximal benefits. The consequences
of inadequate atropine therapy are to be feared
far more than the dangers of over atropiniza-
tion.4
Pralidoxime is administered after completion
of atropinization. This agent which was intro-
duced in late 1964 after extensive clinical trials
not only combines with the unreacted organo-
phosphate but will hydrolyze the initial (es-
teratic) complex formed between the inhibitor
and the cholinesterases. Pralidoxime is par-
ticularly effective in antagonizing the neuro-
muscular blocking (nicotinic) action of the or-
ganophosphates, but unlike atropine has little
effect on their visceral (muscarinic) action. The
effectiveness of pralidoxime in the treatment of
anticholinesterase poisoning has been repeatedly
demonstrated.5’ 9* 10 The usual adult dose is 1
gm by intravenous infusion. If muscular weak-
ness persists an additional dose of 1 gm may be
administered intravenously or orally. However,
since pralidoxime will only hydrolyze the insec-
ticide-cholinesterase complex at the esteratic
bond, it is of little value after the anionic bond
has formed, and the drug probably should not
be continued beyond 24 hours after exposure.
Also, great care should be exercised to avoid
pralidoxime overdosage. This drug, in itself, is
a weak cholinesterase inhibitor.5 Treatment
other than atropine and pralidoxime is symp-
tomatic.
In addition to the actual treatment of the
organophosphate poisoning, consideration must
be given to termination of patient’s exposure as
well as prevention of the exposure of the at-
tending personnel. Usually if the treatment is
carried out in a well-ventilated area and the
attending personnel wear ordinary surgical
gloves, there is little hazard. However, all con-
taminated clothing should be removed from the
patient and laundered. The patient should be
bathed with generous amounts of soap and
water. Washing soda, baking soda or even
bleach may be added to the bath to facilitate
the hydrolysis of the insecticide. This should
be followed by washing splash areas with al-
cohol. If the material has been splashed in the
eyes, they should be irrigated with copious
amounts of tap water or saline. On ingestion,
gastric lavage with water or dilute sodium bi-
carbonate solution would be indicated. This
should be followed by a saline cathartic, pre-
ferably sodium sulfate.
The Chlorinated Hydrocarbon Insecticides
The chlorinated hydrocarbons were the first
to receive wide acceptance as insecticides and
agricultural pesticides in this country. They
constitute more than 50% of the total U. S.
production of pesticides.2 Accounting for about
20% of the cases of poisoning due to pesticides,
the chlorinated hydrocarbons offer less hazard
to man than the organophosphates. Those
recommended for use in South Dakota3 are
listed in decreasing order of their toxicity in
Table II.
TABLE II.
Major Chlorinated Hydrocarbon Insecticides
Recommended for use in South Dakota
Endrin
Lindane
Chlorobenzilate
Thiodan
Toxaphene
Dimite
Dieldrin
Heptachlor
Kelthane
Aldrin
DDT
Methoxychlor
The chlorinated hydrocarbon insecticides, as
the name implies, have a common chemical
composition. Beyond this broad similarity, how-
ever, they vary widely in their chemical struc-
ture, their insecticidal activity, and their
toxicity. All are absorbed from the respiratory
tract or following ingestion. Some, however,
like aldrin, dieldrin and endrin may be ab-
sorbed with sufficient rapidity from the skin or
mucous membranes to cause acute intoxica-
tion.11 Cutaneous absorption of others, as lin-
dane or DDT, is less efficient.
On absorption, aldrin and heptachlor are
rapidly converted to their more toxic epoxides,
dieldrin and endrin.11 The initial metabolites
of the other chlorinated hydrocarbons, however,
are probably less toxic than their parent com-
pounds. All chlorinated hydrocarbons, includ-
ing dieldrin and endrin, are slowly metabolized
or eliminated. In man dieldrin is eliminated in
— 27 —
SOUTH DAKOTA
the urine in the form of at least five meta-
bolites; DDT, primarily as DDA [2,2 bis (para-
chlorphenyl) acetic acid].12 Of the other agents,
traces may be excreted unchanged in the urine,
but for the most part their metabolic fate is un-
known.
The pharmacology of the chlorinated hydro-
carbons has been subjected to extensive inves-
tigation, but the mechanism of action has not
been determined for a single member of the
group. The primary site of action appears to be
the cerebellum.13 Typical signs of poisoning
may be induced in animals following decerebra-
tion. On the other hand, removal of the cere-
bellum or spinal section will reduce the inten-
sity of the symptoms, but only section of the
motor nerves will completely abolish the mus-
cular actions.
The symptoms of poisoning regardless of the
chlorinated hydrocarbon involved are similar.
Mild cases are characterized by headache,
dizziness, gastrointestinal disturbances, numb-
ness and weakness of the extremities, apprehen-
sion, and hypersensitivity to external stimuli.
In more severe cases, fine muscular tremors ap-
pear, spreading from the head to the extrem-
ities. Eventually, there are jerking movements
involving whole muscle groups and finally con-
vulsions.13 Death due to cardiac or respiratory
arrest occurs during convulsions.
In addition to the above there may be poly-
neuropathy, jaundice and circulatory disturb-
ances. The latter result from disturbances
in autonomic function. DDT, for example,
appears to block vagal transmission and prob-
ably choline acetylation,1 4 while the late stages
of both dieldrin and endrin poisoning are
characterized by a marked bradycardia as the
result of stimulation of the vagal centers.15 On
the other hand, aldrin and heptachlor, their
epoxides, dieldrin and endrin as well as DDT,
release catecholamines.16’ 17 It is not known
whether this release is due to a direct peripheral
action or is secondary to a stimulation of the
adrenergic centers. The release of catecholam-
ines, however, may be accompanied by a marked
elevation in peripheral resistance.16 Also, there
may be tachycardia and ventricular arrhyth-
mias.13
Polyneuropathy is rare, but two cases have
been reported, one following exposure to a mix-
ture of DDD and aldrin and the other following
exposure to a mixture of DDT and endrin.18
Recovery was slow, but apparently complete.
Chronic intoxication from exposure to the
chlorinated hydrocarbons is far more common
than with the organophosphate insecticides. The
relative stability of these agents favors per-
sistent residues on food products and slow elim-
ination, their accumulation in body tissues,
especially fat. 1 2 There is no place in the world
where chlorinated hydrocarbon residues have
not been found in the food chain or in the
tissues of man. The average daily dietary in-
take of DDT is about 180 meg. The average
level of storage of DDT (DDT and metabolites)
in man in this country is about 12 ppm, of lin-
dane 0.2 ppm and of dieldrin 0.15 ppm.20 How-
ever, there has been little or no change in the
level of tissue chlorinated hydrocarbon storage
in the U. S. over the past 10 to 15 years.20 The
level of dietary intake of DDT probably could
be increased by 200 fold without detectable
evidence of injury, but manifestations of
chronic intoxication could be anticipated if the
daily intake was increased much above this
level. The intensity of the symptoms of chronic
intoxication is in direct relation to the con-
centration of insecticide in tissue and is com-
parable to those of acute poisoning.
There are no specific antidotes for the treat-
ment of poisoning produced by the chlorinated
hydrocarbon insecticides. Of necessity, treat-
ment is symptomatic and supportive.21 If the
symptoms are mild, small, divided oral doses of
pentobarbital sodium may be adequate to con-
trol the hyperirritability. If the poisoning is
severe, that is if there are muscular tremors
and/or convulsions, thiopental sodium should be
immediately administered intravenously in a
dose adequate to control the symptoms. This
should be followed as necessary by intravenous
or oral doses of pentobarbital sodium sufficient
to maintain control. Calcium gluconate may be
of value as a supplement in severe poisoning,
but it should not be employed as a substitute
for barbiturate therapy. Other treatment would
be purely supportive. The use of sympatho-
mimetic agents, atropine, morphine, or mor-
phine derivatives, is contraindicated. Recovery
is usually rapid and complete, but in cases of
polyneuropathy may require a month or more.
If muscular tremors and/or convulsions persist
for longer than a week, some other causative
factor should be sought.21
As with the organophosphate insecticides, as
soon as the symptoms of chlorinated hydro-
carbon intoxication have been controlled, meas-
ures should be instituted to terminate exposure.
The methods employed are the same as those
for termination of exposure to the organo-
phosphate insecticides.
— 28 —
MARCH 1967
Conclusion
The insecticides, in particular the organo-
phosphates and the chlorinated hydrocarbons,
are highly toxic agents and frequently are the
cause of poisoning in both man and animals.
The present paper was not intended as a com-
prehensive review of intoxication by these
agents, or the methods of treatment, but rather
to emphasize that with prompt and adequate
therapy, an uneventful recovery can be antici-
pated. Even in severe cases when neurological
or liver and kidney damage are obvious, pa-
tients have completely recovered. It is most sig-
nificant that when recovery has been attained,
no sequelae have been noted and the patients
have not demonstrated further complications.
REFERENCES
14. Bleiberg, M. J., Cefaratti, M., Klinman, N. and
Kornblith, P. Studies of Choline Acetylase In-
hibition by DDA (Dichlorodiphenylacetic Acid)
and Its Possible Relationship to DDT Toxicity.
Toxic, appl. Pharmac. 4:292 (May) 1962.
15. Faust, S. A. Pollution of the Water Environment
by Organic Pesticides. Clin. Pharmac. Therap.
5:677, (November-December) 1964.
16. Emerson, T. E. and Henshaw, L. B. Peripheral
Vascular Effects of the Insecticide Endrin. Can. J.
Physiol. Pharmac. 43:531, (July) 1965.
17. Stavinoha, W. B. and Reiger, J. A., Jr., Effect of
DDT on the Urinary Excretion of Epinephrine
and Norepinephrine by Rats. Toxic appl. Pharmac.
8:365, (May) 1966.
18. Jenkins, R. B. and Toole, J. F. Polyneuropathy
Following Exposure to Insecticides. Archs. inter.
Med. 113:691, (May) 1964.
19. Quinby, G. E., Armstrong, J. F. and Durham,
W. F. DDT in Human Milk. Nature 207:726, (Aug.
14) 1965.
20. Hayes, W. J. Occurrence of Poisoning by Pesti-
cides. Archs. envir. Hlth. 9:621, (Nov.) 1964.
21. Princi, F. Toxicology, Diagnosis, and Treatment of
Chlorinated Hydrocarbon Insecticide Intoxication.
Archs. ind. Hlth. 16:333, (Oct.) 1957.
1. Spoor, R. P. and Spencer, J. N. Poisoning in South
Dakota. S.D.J. Med. (In Press).
2. Kay, K. Recent Advances in Research on En-
vironmental Toxicology of the Agricultural Occu-
pations. Am. J. Pub. Hlth. 55: #7 pt. II; 1, (July)
1965.
3. Kantak, B. H. and Berndt, W. R. 1966 South Da-
kota Insecticide Recommendations. Cooperative
Extension Service, South Dakota State University,
Brookings, South Dakota.
4. Holmstedt, B. Pharmacology of Organophosphorus
Cholinesterase Inhibitors. Pharmac. Rev. 11:567,
(Sept.) 1959.
5. Durham, W. F. and Hayes, W. J. Organic Phos-
phorus Poisoning and Its Therapy. Archs. envir.
Hlth. 5:21, (July) 1962.
6. Gershon, S. and Shaw, F. H. Psychiatric Sequelae
of Chronic Exposure to Organophosphate Insec-
ticides. Lancet 1:1371, (June 24) 1961.
7. Zavon, M. R. Blood Cholinesterase Levels in Or-
ganic Phosphate Intoxication. J. Am. Med. Assoc.
192:51, (April 5) 1965.
8. Bowers, M. B., Goodman, E. and Sim, V. M. Some
Behavioral Changes in Man following Anticho-
linesterase Administration. J. nerv. ment. Dis.
138:383, (April) 1964.
9. Done, A. K. Clinical Pharmacology of Systemic
Antidotes. Clin. Pharmac. Ther. 2:750, (Nov.) 1961.
10. Verhulst, H. L. and Page, L. A. A New Agent in
Parathion Poisoning. J. New Drugs 1:80, (March-
April) 1961.
11. Hayes, W. J. Clinical Handbook on Economic
Poisons. Public Health Service Publication #476.
U. S. Government Printing Office, Washington,
D. C. 1963.
12. Hayes, W. J. Review of the Metabolism of Chlor-
inated Hydrocarbon Insecticides Especially in
Mammals. A. Rev. Pharmac. 5:27, 1965.
13. Winteringham, F. P. W. and Barnes, J. M. Com-
parative Response of Insects and Mammals to
Certain Halogenated Hydrocarbons Used as In-
secticides. Physiol. Rev. 35:701, (July) 1955.
standard and custom
EVEREST t JENNINGS
FOLDING
WHEEL
CHAIRS
ALSO
WALKERS
CRUTCHES
PATIENT LIFTS
COMMODES
Rentals * Sales
Kreiser Surgical, Inc.
Sioux Falls Rapid City
— 29 —
ANTIMICROBIAL THERAPY IN PEDIATRICS
By
James N. Elieldorf, M.D. and
Editor's Note: The opinions expressed in this paper
are those of the author and do not reflect those of
the editorial staff of this Journal.
Intelligent use of antimicrobial agents is
largely responsible for the improved mortality
and morbidity and reduced sequelae from bac-
terial infections. Despite many advantages at-
tendant with their use, certain comments are in
order before entering into a discussion or re-
view of the use of antibiotics in pediatric prac-
tice.
Much information, perhaps too much, directed
mainly toward encouraging the use of an ever
increasing number of antibiotics, has appeared
in form of lectures, treatises, scientific articles,
advertisements, etc. during the past decade or
two. All too often we depend entirely upon
“Professional Service Men” and advertisements
for sources of scientific information. Because of
the inherent bias associated with such informa-
tion, needless use of these agents follows. If this
presentation will result in more selective and
discriminant use of antimicrobials, it will have
accomplished a major portion of our objective.
Let us ask ourselves a few questions in order
to analyze our practices. How often have these
agents been prescribed by telephone without
examining the patient? Have we advised the
patient and the pharmacists that these agents
are not to be refilled in order to prevent repe-
titious use to the patient or another person?
How many prescriptions are written for these
agents merely because the patient expects it or
because it is felt that the antibiotic is harmless
— only to determine later that resistant strains
of bacteria have developed, that teeth are perm-
anently discolored, etc.? How many patients
with nonbacterial upper respiratory infections
are receiving antibiotics? In how may instances
* Department of Pediatrics College of Medicine, Uni-
versity of Tennessee and Le Bonheur Children’s
Hospital, Memphis, Tennessee.
Presented at the Annual Meeting of the South Da-
kota State Medical Association, Huron, South Da-
kota, May 21-24, 1966.
Stanley E. Crawford, M.D.*
of viral infections has penicillin been changed
to such potentially dangerous agents as chlor-
amphenicol? How many still consider chlor-
amphenicol the agent of choice in infections and
are not cognizant of the fact or are unwilling to
accept that this agent is capable of causing
severe life threatening reactions which limit its
use to a few specific indications? How many
children with measles, chickenpox, etc. receive
penicillin or broad-spectrum antibiotics to pre-
vent “secondary infections”? How many pa-
tients receive antibiotics routinely following
clean surgical procedures?
We all should remember:
1) That these agents are not harmless.
2) Usually newness doesn’t imply superiority.
3) Thorough understanding and use of few
antibiotics are preferable to superficial
knowledge and use of many.
Antibiotics may conveniently be divided ac-
cording to mode of action into the following
categories:
1. Bactericidal — with action directed toward
cell wall.
2. Bacteriostatic — (a) those with action di-
rected toward synthesis of RNA and other
proteins, i.e., enzymes etc. (b) those which
interfere with intermediary metabolism of
the cell.
Bactericidal agents which act primarily by
disturbing the synthesis, permeability, or func-
tion of the bacterial cell wall or membrane in-
clude the penicillins, the cephalosporins, baci-
tracin, vancomycin, ristocetin, novobiocin, the
amino-glucosides such as streptomycin, kana-
mycin, neomycin, and the polymyxins. Ampho-
tericin B and nystatin, two commonly used
fungicidal agents, also have their site of action
in the cell membrane. Control of infections due
to gram-positive organisms is more satisfactory
than those caused by gram-negative bacteria.
— 30 —
MARCH 1967
This phenomenon may be related to composition
of the cell wall. The wall of the gram-positive
organism is composed of amino acids and amino
sugars whereas cell wall of the gram-negative
organisms is more complex consisting of amino
acids, amino sugars and also lipids.1
Bacteriostatic and cytotoxic agents exert their
effect by interfering with the biosynthesis of
proteins. Included in this group are the tetra-
cyclines, chloramphenicol, erythromycin, and
oleandomycin. Another group of agents, which
are bacteriostatic and affect the intermediary
metabolism of the cell, include the sulfonamides
which are structurally and biologically similar
to para-aminobenzoic acid and inhibit the for-
mation of folic acid.2 In addition, anti-
tuberculous agents such as para-aminosalicylic
acid and isoniazid are included in this group.
The usefulness of the available antibacterial
agents depends upon many considerations in-
cluding dosage and route of administration. One
drug correctly used is generally to be preferred
over a battery of agents. Selectivity of the
agents with genuine indications based on cul-
tures and sensitivity tests, when indicated, and
used in adequate dosage for sufficient time with
due respect to toxic effect is essential for suc-
cess in managing infections.
Recommendations for specific infections:
Group A streptococci:
The beta hemolytic streptococcus Group A
through two decades has remained sensitive to
penicillin and in the absence of allergic or other
sensitivity reactions is the drug of choice in
combating these infections. Ten days of therapy
are recommended.3 Cultures of the throat and
nasopharynx are necessary to establish a diag-
nosis. In our experience, only 12% of sore
throats are attributed to beta streptococci. Sen-
sitivity tests against this organism represent
needless expense and only misinformation can
be obtained. Penicillin-G potassium or procaine
penicillin-G, phenoxymethyl penicillin (Peni-
cillin V) or benzathine penicillin-G (Bicillin) are
the forms of choice. Bicillin intramuscularly is
adequate in streptococcal infections.4 How-
ever, early treatment with rapid acting penicil-
lin is indicated in serious and overwhelming
streptococcosis.
Recently, it has been suggested that treat-
ment failures of oral penicillin may be related
to the presence of a penicillinase producing
staphylococcus which colonizes the nasopharynx
along with the streptococcus.5- 6 However,
there is no evidence for resistance to therapy
with intramuscular penicillin including Bicillin.
If the child is penicillin sensitive, either
erythromycin or triacetyloleandomycin (TAO)
may be used. The estolate form of erythro-
mycin (Ilosone) occasionally produces cholestatic
jaundice in adults; but not in children.7 Tri-
acetyloleandomycin is more toxic than erythro-
mycin causing not only cholestasis but also
rashes, neutropenia, and rarely platelet sup-
pression; drug fever occurs occasionally. It is
unfortunate that TAO is marketed in combina-
tion with tetracycline for this combination is
irrational and not backed by evidence of syner-
gism. Another combination is tetracycline plus
novobiocin.
The beta hemolytic streptococcus is not erad-
icated with sulfonamides and they should not
be used in treatment of active infection. How-
ever, their use in prophylaxis of acute rheu-
matic fever remains satisfactory in the general
population. In military populations, sulfon-
amides used prophylactically have resulted in
emergence of resistant strains of streptococci.8
The usual disk sensitivity test is neither re-
quired nor reliable.
There are several well documented studies
showing that 32% of isolated group A beta
hemolytic streptococci are resistant to tetra-
cycline. This includes the nephritogenic type
12. 9 Consequently, their usefulness in these in-
fections is limited.
Cephalothin, a relatively new drug, has been
recommended for use if the patient is penicillin
sensitive.10 However, this is impractical for
office use because it must be given either intra-
muscularly or intravenously every 4 to 6 hours
in present dosage forms.
Chloramphenicol may properly be regarded
as a potentially dangerous drug. It has limited
usefulness in general, and has no place in the
treatment of streptococcal infections. Chlor-
amphenicol blocks protein synthesis. It blocks
the ribosomal binding sites for messenger RNA
and thus suppresses antibody formation.11 This
agent also produces RBC maturation arrest,
and at times, aplastic anemia may result un-
related to dosage or duration of therapy.
Phenylalanine, an amino acid, has partially re-
versed some of the cellular toxic vacuolizations
but its true effect in altering toxicity remains
to be proven.12
31 —
SOUTH DAKOTA
Pneumococcal Infections:
Although pneumococci have been demon-
strated to be resistant to penicillin in vitro, it
remains the drug of choice in the treatment of
these infections with erythromycin being use-
ful in patients who are sensitive to penicil-
lin.13- 14 Therapy in pneumococcal pneumonia
is continued for 7-10 days and for at least two
full weeks in a pneumococcal meningitis in high
dosage.
Approximately 2% of pneumococci are now
resistant to tetracycline therapy.15 These re-
sistant organisms are found (a) in patients who
are receiving tetracycline at the time pneu-
monia develops or (b) among hospitalized pa-
tients. Sulfonamide resistant pneumococci are
well known.
The physician must be aware that many
nasopharyngeal cultures yield pneumococci dur-
ing Winter and Spring which may be unrelated
to disease of the lower respiratory tract. Pneu-
mococcus is rarely responsible for sore throat.
Hemophilus influenzae infections:
Hemophilus influenzae infections may be
treated with a number of agents. Tetracycline
may be used for less severe infections and has
been recommended by some in meningitis. How-
ever, most authorities recommend chloram-
phenicol for Hemophilus influenzae meningitis.
The place of ampicillin in the therapy of menin-
gitis is under evaluation. Reports of cases
treated with ampicillin alone seem as satisfac-
tory as the triple drug approach for menin-
gitis.16 The dose for ampicillin in the therapy
of meningitis is 150 mg. /Kg. /day given every
6 hours parenterally.
Antimicrobials in otitis media:
The treatment of suppurative otitis media
must take into consideration causative bacteria.
Bacterial pathogens known to produce this en-
tity include streptococcus, pneumococcus,
Hemophilus influenzae, and in a few instances,
staphylococcus. The combination of penicillin
and sulfa therapy for 7-10 days is widely recom-
mended. Tetracycline may be useful, but one
must appreciate the undesirable effects, i.e.,
dental staining, development of resistant strains,
monilia enteritis and proctitis and elimination
of normal flora. Ampicillin in the dosage of 50-
75 mg./Kg./day is a useful alternative.
Meningococci:
Because of the development of sulfonamide
resistance by certain strains of meningococci,
penicillin in generous amounts has become the
agent of choice in treating this infection.
Cephalothin (50-100 mg./Kg./day) or erythro-
mycin my be tried if the patient is penicillin
sensitive in the presence of sulfonamide re-
sistant strains. Ampicillin is proving a useful
agent. At present, we recommend using both
sulfadiazine or sulfisoxazole (Gantrisin) and
penicillin while awaiting results of sensitivity
studies on Mueller-Hinton agar.
Until recently, sulfadiazine has been the
standard by which effectiveness of other drugs
was measured. Two grams daily for 2-3 days
would reduce a population carrier rate from
80% to less than 1%. It was considered as the
therapeutic agent of choice until 1963 when 7
out of 8 strains tested in a confined population
revealed marked sulfonamide resistance. Sul-
fadiazine only reduced the carrier rate from
57% to 49% at the U. S. Naval Training Center
in San Diego. 1 7 Resistant organisms were later
noted at Fort Ord,18 then throughout Cali-
fornia.19 We have had three such cases in our
hospital. Whereas the usual meningococcus
causing meningitis has been group A in the past,
currently the resistant strains often belong to
group B or C.
No satisfactory substitute for sulfadiazine as
a prophylactic agent is yet available for the
resistant strains. Oral penicillin-G in doses of
1 million units/day for 4 days was not effective
in eradicating the carrier state.17 These sulfa
resistant strains are sensitive to ampicillin and
chloramphenicol; however, toxicity of the latter
excludes its use. In view of these observations,
prophylaxis for adults includes 2 grams of sulfa
daily for two days and, in addition, four days
of penicillin therapy.
Slaphylococcal infections:
The problem of the resistant staphylococcus
is familiar to clinicians. Wide usage of anti-
biotics has eliminated sensitive strains only to
allow resistant ones to develop. Although cer-
tain types have been classically associated with
nursery epidemics and infections in the mother,
there is no evidence that the penicillin resistant
strains are more virulent than the penicillin
sensitive strains. Host resistance becomes im-
portant in dealing with the treatment of the
staphylococcal infection. Patients with conges-
tive failure and diabetes are prone to develop
staphylococcal infections. In pediatric practice,
premature infants, children with cystic fibrosis
of the pancreas and leukemia patients are often
infected by the staphylococci.
The outcome of treatment depends upon fac-
tors other than a consideration of the antibiotic
— 32 —
MARCH 1967
agent alone. A foreign body may need removal;
collections of pus must be adequately drained.
Certain staphylococcal infections such as para-
vertebral abscess, an epidural abscess and other
abscesses or an acute spondylitis, are diagnosed
late and early therapy is often inadequate.
The choice of an antibiotic must depend upon
culture and sensitivity guidance, and bac-
tericidal drugs are preferred. While awaiting
the results of cultures, most authorities would
recommend the use of the newer penicillinase
resistant penicillins.
Resistance to penicillin is mainly attributable
to penicillinase, an enzyme originally found in
some strains of E. coli but widely distributed
among both gram-positive and gram-negative
bacteria, which destroys the action of penicillin
producing a product which is inactive.
Approximately two-thirds of all staphylococci
from hospitalized patients are now resistant to
penicillin-G. However, a majority of “street”
strains remain sensitive to penicillin and it
should be used in these cases. One-third are
resistant to tetracycline, erythromycin, chlor-
amphenicol and novobiocin. All strains, how-
ever, remain sensitive to bacitracin and vanco-
mycin. Surveillance by a number of hospitals
in England has detected methicillin (Staph-
cillin) resistant staphylococci. Four percent of
staphylococci isolated from hospital sources are
now resistant to this and similar agents.20
The new penicillins which are resistant to
penicillinase all have the same basic structure
as penicillin-G. Chemically, they are composed
of five ring structure (thiazolidine) and, in ad-
dition, the B-lactam ring.21 The antistaphy-
lococcal penicillins available include methicillin
(Staphcillin) which may only be given intra-
venously or intramuscularly, oxacillin (Prosta-
phlin), nafcillin (Unipen) and cloxacillin (Tego
Pen). The latter three agents may be given
orally or parenterally. The anti-staph penicillins
are less potent than penicillin-G against penicil-
lin-G-sensitive organisms, and all are somewhat
more toxic than the parent molecule. Tissue
levels are low unless large doses are used; there-
fore, in severe illness, dosages from 100-300
mg./Kg./day are recommended. Kidney toxicity
has been noted in excess of 300 mg./Kg./day;
agranulocytosis has been reported with methi-
cillin but was reversible. All of the antistaph
penicillins are given in 4-6 doses daily and all
should be given parenterally if the infection is
severe. These agents currently are the drugs of
choice in staphylococcal infections resistant to
penicillin-G, but cannot be used if the patient
is penicillin sensitive. There is no reason for
selecting one anti-staphylococcal penicillin in
preference to another.22
Although too nephrotoxic in older children
and adults, bacitracin is an excellent drug for
severe staphylococcal disease in infants less
than one year of age. It is virtually nontoxic in
dosage of 800-1000 units/Kg. /day. It is given
intramuscularly every 12 hours with a freshly
prepared solution for each 24 hour period. It
may be given from 1 to 2 weeks after which
therapy should be switched to another agent
such as oxacillin or one of the other penicillinase
resistant penicillins, if additional therapy is in-
dicated.23
Cephalothin, only available for parenteral in-
jections, is highly efficient in eradicating infec-
tion and deserves serious consideration in these
infections despite its current cost.
Vancomycin in doses of 40 to 60 mg./Kg./day
must be given intravenously as a continuous in-
fusion or four divided doses. This agent pos-
sesses eighth nerve toxicity. It may cause
thromboses at injection sites, eosinophilia; drug
fever and occasional renal damage have also
been observed. Also, allergic reactions of an
anaphylactoid nature and peripheral neuropathy
are hazards in its use. It can only be recom-
mended at the present time in penicillin sen-
sitive subjects, and those with no overtones of
renal problems. The adult dose will average
2 gms./day.22
Salmonella and Shigella infections:
Chloramphenicol is still regarded as the drug
of choice for salmonella including typhoid fever;
however, ampicillin has been successfully used
in severe infections and now holds promise of
possibly eradicating typhoid carriers. Tetra-
cycline continues to be of value when treating
infections due to most strains of shigella. Am-
picillin is also effective.24
Gonococcal infections:
Resistance of gonococci to sulfonamide
rapidly developed during World War II when
gonorrheal urethritis was again controlled by
penicillin therapy. Larger doses of penicillin
are now necessary as this organism has become
less susceptible. Also, rapid streptomycin resist-
ance has emerged during this period. The drug
of choice at this time in the adolescent with
urethritis is a minimal dosage of 2.4 million
units of procaine penicillin. Patients not re-
sponding are treated with either tetracycline or
erythromycin over a four day period.
33
SOUTH DAKOTA
Usefulness of new broad-speclrum-anfibiolics:
Ampicillin has no place in the therapy for
penicillinase producing staphylococci; however,
it has great clinical usefulness in a variety of
infections, some of which have been discussed
previously, because it possesses broad-spectrum
activity. It is now available in preparations for
parenteral as well as oral use. Toxicity to orally
administered ampicillin includes nausea, vomit-
ing and diarrhea. Patients may also exhibit
eosinophilia. It is essentially nontoxic to the
kidney. Dosage recommendations vary from 50-
150 mg. /Kg. /day at four to six hour intervals.
It appears to be an agent of choice in shigella
and pertussis infections,25- 26 and is useful in
certain Salmonella infections including typhoid
fever. Ampicillin is recommended for eradica-
tion of the typhoid carrier state.27 Approx-
imately 60% of E. coli infections are susceptible
to this agent; however, the pseudomonas, kleb-
siella, aerobacter aerogenes, the indole-positive
proteus, are resistant to ampicillin.
Cephalothin (Keflin) a non penicillin deriva-
tive is not affected by penicillinase and is effec-
tive against resistant staphylococcus. Although
anaphylactoid reactions have been reported with
its use, those who are allergic to penicillin
usually tolerate this drug. It is not absorbed
from the gastrointestinal tract and has caused
rashes, transaminase elevation, and rare neu-
tropenia. Its effects are somewhat unpredict-
able but it appears to control a fairly wide spec-
trum of infectious organisms such as Group A
hemolytic streptococci; streptococcus viridans,
enterococci, pneumococci, non-penicillinase as
well as penicillinase producing staphylococci.
Meningococcal, gonococcal, and diphtheria in-
fections are reportedly sensitive to this agent.
To a lesser extent, the Salmonella group of or-
ganisms including typhoid, proteus mirabilis,
and certain strains of E. coli are also sensitive.
About half of the strains of Shigella tested are
sensitive to cephalothin; many strains of H. in-
fluenzae have been resistant.28
Some authorities are recommending cepha-
lothin as the drug of choice in suspected bac-
terial sepsis in adults until results of cultures
are obtained.10 It has no nephrotoxicity. It is
primarily limited to hospital use and often a
more effective drug is available. The dosage in
adults has ranged between 2 and 8 grams daily;
the child 40 and 80 mg. /Kg. /day intramus-
cularly or intravenously every 6 hours is recom-
mended.
Urinary Tract infections:
Again cultures and sensitivity studies should
form the guidelines in the management of in-
fections of the urinary tract with great respect
for underlying urinary tract anomalies.
A sulfonamide in the form of sulfisoxazole
or triple sulfonamides given for a period of two
to three weeks represents a wise choice for
initial acute urinary tract infections. The newer
long acting sulfonamide agents have increased
the incidence of the Stevens- Johnson syn-
drome29 and are mentioned only to be con-
demned. For severe urinary tract infections
(pyelonephritis), especially those due to E. coli,
kanamycin in dosage of 15 mg./Kg./day given
on a 12 hour basis for 10-12 days is often useful
despite its nephrotoxicity. Ampicillin and
cephalothin are used if the organism is known
to be susceptible and if the BUN is elevated in-
dicating reduced renal function. Tetracyclines
may be used in urinary tract infection due to
sensitive organisms but may increase a pre-
existing elevation in BUN. We wish to em-
phasize that tubular damage resulting in a Fan-
coni-like syndrome may follow administration
of an outdated tetracycline.30
Infections of the urinary tract due to strep-
tococcus faecalis may respond to erythromycin;
proteus mirabilis is usually sensitive to ampi-
cillin, nalidixic acid (NegGram) and cepha-
lothin. Infections with indole-positive strains of
proteus such as vulgaris and morgagni often
respond to kanamycin and on occasion to novo-
biocin; chloramphenicol may be used when
other agents fail.
The pseudomonas infections, regardless of
site, remain to be a difficult problem. The poly-
myxins, either polymyxin B or polymyxin-E
(colistimethate) are recommended in dosage of
2.5 mg. and 5 mg./Kg./day respectively. A new
drug, gentamicin, may be helpful but neither
efficacy nor safety are established.31
Nalidixic acid, an agent which is not related
to any other antimicrobial, results in relatively
low tissue levels and rapid bacterial resistance
has developed while on therapy. In high dosage,
it may nrecioitate convulsions in a child with
this diathesis; it causes gastritis with nausea and
vomiting and skin rashes. Nalidixic acid is not
effective against the pseudomonas. Dosage is
50 mg./Kg./day by mouth in four divided doses.
Furadantin, which produces undesirable side
effects, is another agent of limited value in
urinary tract infections and requires an acid
urine. Its use results in low tissue levels and its
34 —
MARCH 1967
efficacy is dependent upon a high urine level.
Peripheral neuropathy may result when reten-
tion occurs. Nitrofurantoin will precipitate
hemolysis of primaquine-sensitive erythrocytes.
It should not be used in infants less than three
months of age.28
The therapy of recurrent or chronic urinary
infections in the absence of stasis, obstruction
or foreign body may require long term drug
prophylaxis. Useful are, nitrofurantoin in re-
duced dosage (3 mg./Kg./day), one of the sul-
fonamides, or mandelamine (2 gm./M2 day),
with an acidifying agent such as ascorbic acid
in similar dosage to keep urinary pH less than
5.5. One should be cautious in interpreting disk
sensitivities to mandelamine since most organ-
isms are inhibited and this may bear no corre-
lation with predictable clinical outcome.
Antibiotics used in treatment of premature and
newborn infants:
Antibotic usage in the premature and newly
born infant requires dosage adjustment with
many drugs, particularly chloramphenicol and
the sulfonamides. Renal functions are sig-
nificantly underdeveloped at this age.32 Of par-
ticular value in this age group is kanamycin,
which is excreted almost entirely in the urine.
It has a prolonged plasma half life, and, there-
fore, dosage may be given at 12 hour intervals
with a reduction in the 24 hour dosage to avoid
toxicity. Bacitracin is less toxic to the neonate
than the older child or adult. Chloramphenicol
is rarely indicated and may cause cardiovas-
cular collapse (gray syndrome) which is not seen
in the older individual. The dose of chloram-
phenicol 25 mg./Kg./day is recommended in
newborns and prematures less than one week,
provided its possible advantages outweigh its
potential undesirable side effects. Blood levels
of 10 to 20 micrograms are generally safe and
may guide its use; however, levels usually are
not obtainable. Repeated reticulocyte counts
which are low may indicate hematological sup-
pression. Maturation arrest of bone marrow
elements reliably indicates hematological sup-
pression at a time when this adverse effect may
be reversible and should be examined approx-
imately every fifth day for meaningful informa-
tion.
Polymyxin B may be given IM in dosage of
3.5 mg./Kg./day for one week. Its sister com-
pound, colstimethate, is given in doses of 6-7
mg./Kg./day in three or four divided doses. In
pseudomonas meningitis, polymyxin 1 mg. daily
may be given intrathecally for several days.
Coly-mycin as now available contains dibucaine,
a local anesthetic, and cannot be used intra-
thecally or intravenously.
The tetracyclines when used in small infants
may occasionally cause pseudo tumor cerebri;
it will consistently be deposited in dental
enamel and cause staining. In addition, growth
is retarded in premature infants and dental
caries are increased. Tetracyclines also cause
retardation of bone growth. Use of these agents
alters normal flora. Agents more desirable than
tetracyclines are usually available for the neo-
nate.
When faced with an infection of unknown
etiology in an infant of this age group, and also
in older children, we utilize penicillin and kana-
mycin. In neonatal meningitis, ampicillin plus
kanamycin is generally used as initial therapy
prior to cultural isolation.
Therapy with combinations of antibiotics:
As stated previously, selective use of a single
antibiotic is preferable to mixtures. Unfortun-
ately, serious infections too often are treated
without initial cultures and sensitivity studies.
Changes in the sensitivity patterns of organ-
isms which occur from year to year place a
greater reliance upon the laboratory; however,
in vitro studies may not agree with the patient’s
course to an agent selected.
In 1950, Hunter reported synergism in the
eradication of enterococcal endocarditis with a
combination of penicillin and streptomycin.33
In 1951, a report appeared showing a higher
mortality rate in pneumococcal meningitis when
treated with penicillin and tetracycline than
when penicillin alone was used. This may rep-
resent an example of drug antagonism.34 In
1956, certain promoters of antibiotics proclaimed
a “third era in antibiotic therapy”35 by market-
ing of tetracycline and oleandomycin. This was
followed by financial success to the promoters
without satisfactory evidence of merit.36
Dowling believes that combinations of bac-
tericidal agents may result in synergism rather
thsn antagonism. On the contrary, if a bac-
tericidal agent and a bacteriostatic one are
paired in therapy, one may find synergism or
antagonism, or neither. If bacteriostatic agents
are used together, neither synergism nor an-
tagonism occur. In actual practice, only the
following combinations may be recommended.
(1) Enterococcal endocarditis is best treated
with penicillin and streptomycin. (2) Although
— 35 —
SOUTH DAKOTA
brucellosis was formerly treated with tetra-
cycline and streptomycin, recent reports demon-
strate tetracycline alone is satisfactory.37 (3) It
is well accepted in tuberculosis to treat with
drug combinations of isonizid, para-aminosali-
cylic acid and for limited periods, streptomycin.
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P. F. and Portnoy, B.: Ampicillin in the treatment
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— 36 —
(jlINICOPATHOIOGICAL CONFERENCE - SIOUX VALLEY HOSPITAL
From the Intern and Resident Teaching Conferences of the Sioux Valley Hospital, Sioux Falls
JOHN F. BARLOW, M.D *
Pathologist-Editor
RICHARD S. HOSEN, M.D.**
Pediatrician-Discusser
This 3-year old white female was well until
3 months prior to admission. At that time she
developed elevation of temperature up to 103°,
joint complaints with mild swelling, listlessness,
and irritability. Her knees hurt when she
walked and her hips, knees, and elbows were
limited on motion because of pain. She also
developed periorbital edema and malar rash.
There was an evanescent rash on the chest and
abdomen. Hemogram showed a hemoglobin of
11.1 gm. % but was otherwise normal. Urinaly-
sis, BUN, uric acid, ECG, ASO titer, latex fixa-
tion test, and throat culture were unremarkable.
The erythrocyte sedimentation was 23 mm/hr.
and 19 mm/hr. Because of back complaints an
x-ray film of the lumbar spine was taken. This
was negative as were films of the pelvis, knees,
and chest. Sinus films revealed maxillary sinu-
sitis. She was given prophylactic penicillin and
aspirin. Over the several weeks prior to her
last admission she developed increasing muscle
weakness and was unable to walk. The perior-
bital edema became more marked.
On admission temperature was 100.8 c, respira-
tion 24/minute and blood pressure 119/78. She
was a well-developed, well-nourished, irritable,
little girl with marked periorbital edema and
reddish discoloration about the eyes. There were
several palpable anterior cervical and posterior
cervical nodes. The lungs were clear. There was
a Grade II late systolic murmur over the left
fourth intercostal space. The abdomen revealed
no enlarged organs. The extremities all showed
non-pitting edema, slight warmth, and tender-
ness but no redness. There was generalized
weakness and she complained of pain on exten-
sion of the extremities. Sensory examination
and reflexes were normal.
Laboratory examination revealed hemoglobin
10.5 gm. %, RBC 4.01 million/mm3, hematocrit
*Lecturer in Pathology, School of Medicine, Univer-
sity of South Dakota.
** Assistant Professor of Pediatrics, School of Med-
icine, University of South Dakota.
33 vol. %, MCH 26 micromicrograms (normal
29 ± 2), MCV 83 cubic micra (normal 94 ± 10),
MCHC 32 (normal 34 ± 2), WBC 7100 with 50%
polys, 3% bands, 43% lymphocytes and 4%
monocytes. Platelets were adequate on smear
and red cells were normochromic and normo-
cytic. Urine was straw colored, cloudy, specific
gravity 1.013, pH 7.0 and negative for protein,
sugar, and hemoglobin. There were 1-3 WBC/
HPF. Sodium was 142 meq/L, potassium 4.4
meq/L. Throat culture revealed normal flora.
Electrophoresis showed albumin 2.8 grams
(normal 3.5-5.95), alpha I. 0.25 gm% (nor-
mal 0.124-0.350), alpha II 0.69 gm% (normal
0.434-0.935), beta 0.61 gms% (normal 0.496-1.119),
and gamma 0.8 gms% (normal 0.558-1.19). Crea-
tine phosphokinase (CPK) was 1200 units (nor-
mal 0-200 units). Lactic Dehydrogenase (LDH)
was 1220 units (normal 0-500 units) but frac-
tionation into its isoenzyme components re-
vealed a non-specific pattern.
The patient’s course in the hospital was
characterized by increasing muscle weakness
necessitating tracheostomy and gavage feedings.
She developed a bilateral lower lobe pulmonary
infiltrate. Her hemoglobin fell as low as 6.7
gms% and she was transfused with two units of
blood. The bleeding was attributed to irritation
by the nasogastric tube. She was treated with
steroids through her hospital course which lasted
thirty-eight days before she was found dead.
CLINICAL DISCUSSION
Dr. Hosen: This little 3-year old girl was well
until three months prior to admission when she
complained of mild joint swelling and was list-
less and irritable. All of these symptoms you
could find in any sick three year old. There
are a number of non-specific joint complaints
associated with viral and bacterial infections in
youngsters. Her knees hurt when she walked.
She had stiff knees and elbows which were
limited on motion. It is a little unusual to have
non-specific joint pains that generalized. Then
she developed periorbital edema and a rash.
— 37 —
SOUTH DAKOTA
At this point I’m sure any alert physician would
think of trichinosis. A hemoglobin of 11.1
gms% we can accept in a three year old child
as normal. Physicians dealing with adults some-
times look on that as anemia; I don’t consider it
such in a child.4
Other chemistries and urinalysis were nor-
mal. The latex fixation test was negative. This
test is not very helpful in children since it is
positive in only about 12% of children with
proven rheumatoid arthritis.5 This points out
one of the differences between adult and
pediatric rheumatoid arthritis. The sed rate was
what could be considered normal in chil-
dren. We often see children who are vaguely ill
perhaps with a poststreptococcal syndrome or
a not so recent bacterial infection with a sed
rate at 23 mm/hr. We are used to seeing levels
of 60 or over in children who have definite col-
lagen disease.
This child’s muscle and joint complaints ex-
tended into the lumbar area. All of her x-rays
were negative. One unusual x-ray finding was
a maxillary sinusitis which is rather rare in
three year old children whose maxillary sinuses
are not very large. She was given penicillin and
aspirin for maxillary sinusitis, and prophylac-
tically because there was a possibility of rheu-
matic fever. She was discharged but increase in
muscle weakness made it difficult for her to
walk. Periorbital edema became more marked.
Again this could be trichinosis although I think
it would be an unusually severe case. There are
many undiagnosed cases of trichinosis. It is
recognized, of course, only in patients with
symptoms but Trichina may be found in one
of every twenty or so people in large scale
studies.6
On final admission her vital signs appeared
normal. The blood pressure of 119/78 is not sig-
nificant for an excited child using a medium-
sized cuff which is used for a three year old.
She was irritable and had marked periorbital
edema with abundant reddish discoloration. This
leads us somewhat away from trichinosis and
makes us consider dermatomyositis. There were
no unusual lymph nodes. There was a heart
murmur (not necessarily significant). We are
not told if it changed with position or exercise.
It sounds like a functional murmur. There is no
known association between dermatomyositis
and cardiac disease. There were no enlarged
organs. Splenomegaly is often seen in dermato-
myositis. The extremities all revealed non-
pitting edema, slight warmth and tenderness,
but no redness. Generalized weakness with
pain on extension of the extremities was noted.
A particular type of edema, a brawny, non-
pitting edema with shiny discoloration over the
joints and extensor surfaces is seen in derma-
tomyositis. I assume this is what this girl had.
The laboratory work is unremarkable. She
didn’t have an eosinophilia which may be seen
with dermatomyositis or trichinosis. There was
some concern about hemostasis. The prothrom-
bin time and partial thromboplastin time
were normal. The platelets were adequate on
smear. This rules out a bleeding deficiency ex-
cept from platelets or capillaries not function-
ing adequately. I don’t think she had any of
these types of bleeding, but she may have been
bleeding from a gastric ulcer. This can be a
problem with steroid therapy. Her electro-
phoretic pattern showed a somewhat depressed
pattern of all protein fractions with nothing
specific. The A/G ratio was inverted. Her
serum gamma globulin was low as was her
albumin. The creatine phosphokinase was
markedly elevated which is expected in severe
muscle disease. Creatine phosphokinase is an
enzyme which catalyzes the removal of phos-
phate from creatine phosphate and adds the phos-
phate to adenosine diphosphate to give adenosine
triphosphate. This enzyme is fairly specific for
muscle and its concentration is easy to deter-
mine. The pathologist doesn’t have to worry
about hemolysis since it is not in the red cells
nor does he have to be concerned about liver
disease since the enzyme is not present in the
liver in high concentration. The LDH was
elevated also but there are at least five iso-
enzymes that have lactic dehydrogenase activ-
ity. Fractionation by electrophoresis is re-
quired: usually if the LDH is from a specific
organ this can be determined by the electro-
phoretic fractionation pattern. This girl did
not have a specific electrophoretic fractionation
pattern.
She continued to have increase in muscle
weakness necessitating tracheostomy and
gavage feedings. She developed a pulmonary
infiltrate which we may assume to have de-
veloped secondary to aspiration. Her hemo-
globin fell as low as 6.7 gm%. This is beyond
what we would expect for generalized anemia
associated with collagen disease. We have to
say that she was bleeding. Gastrointestinal
ulcers are common in children treated with
steroids and are frequently seen in children
with dermatomyositis or other collagen diseases.
(Continued on Page 47)
38
MARCH 1967
(Continued from Page 38)
Gastrointestinal ulcers have been found in chil-
dren with dermatomyositis prior to the avail-
ability of steroids. This ulcer could be anywhere
in the gastrointestinal tract. It could be in the
esophagus where it could have perforated and
caused a mediastinitis. It could have been in
the duodenum with perforation and peritonitis
or she could have bled from a lower gastro-
intestinal tract ulcer.
Unfortunately steroid therapy is about all we
have to offer in treating polymyositis or derma-
tomyositis. I feel she probably died because of
massive aspiration of gastric contents. This is
the type of death that is most common in chil-
dren with polymyositis and dermatomyositis,
and is a manner of death seen increasingly with
steroid treatment in children who have lasted
long enough to have prolonged muscle weak-
ness. I think she had dermatomyositis and it
might be academic to argue whether from this
protocol we can say that she had polymyositis
instead of dermatomyositis. Both can be asso-
ciated with an evanescent rash. The malar rash
seems florid as does the periorbital edema but
we don’t have a good description of the dis-
coloration over the joints and extensor surfaces.
Dermatomyositis is not necessarily a fatal dis-
ease. It can go into remission although exacer-
bations are common. The children who have
the best prognosis have the most subcutaneous
calcification probably because it takes time to
develop subcutaneous calcification and children
with a poor prognosis die too rapidly to develop
it.
We would like to have another enzyme de-
termination — an aldolase. It has been stated
that the CPK gives us everything in the way of
information in muscle disease. This is true ex-
cept for this one disease — dermatomyositis in
which the aldolase is invariably elevated7
which is not true of the CPK. Perhaps aldolase
is not that useful in this patient since it is
elevated in the newborn and does not reach
adult levels until adolescence, and it would be
anticipated that a three-year old would have a
somewhat elevated aldolase. However, I think
with dermatomyositis it would have been mark-
edly elevated. In girls also in the first few years
of life the aldolase is elevated over the level of
boys. It is about 15-35% higher in girls up to
age 2 than it is in boys.
The differential diagnosis in this girl would
include trichinosis which could be diagnosed
by skin test, serum tests and muscle biopsy.
Lupus erythematosis could, of course, produce
muscle and joint disease and malar rash. In
lupus there should be an elevated gamma
globulin which this patient did not have and
I’m sure she must have had a negative L. E.
preparation. We certainly couldn’t rule out rheu-
matoid arthritis by a negative latex fixation
test as mentioned. However, there should be an
elevated gamma globulin in rheumatoid arth-
ritis. Moreover, this girl’s difficulty was pre-
dominantly muscular rather than in joints.
We talked about the difference between der-
matomyositis and polymyositis. There are other
syndromes that closely simulate either of the
above in children. One is congenital agamma-
globulinemia which we have seen from the elec-
trophoresis was not present here. With agam-
maglobulinemia some children have muscle
tenderness and weakness, rash, tenseness, and
discoloration over the joints particularly over
the extensor surfaces but do not seem to have
a malar rash. In malignancies in some chil-
dren there has been a dermatomyositis-like ill-
ness with muscle lesions and discoloration over
the extremities. The incidence of malignancy
is apparently high. In the literature there is
an incidence of approximately 18% of children
with carcinoma associated with some features
of dermatomyositis-like syndrome.8 It would
be unusual for this child to have malignancy
with this sed rate whereas she could have had
dermatomyositis with a 23 and 19 mm/hr. sed
rate. Dermatomyositis is placed in the collagen
disease group simply because it resembles many
of our collagen diseases and we have no specific
etiology and no specific serum tests except the
enzyme tests as mentioned previously. It is
felt that dermatomyositis is a hypersensitivity
syndrome associated with an altered reaction
to a child’s tumor cells or perhaps to normal
skin and muscle tissue. I think that in this little
girl we’ll find muscle and vascular pathology
that is typical of dermatomyositis and most
likely a gastrointestinal ulcer along with gas-
tric aspiration. Are there any questions?
Dr. D. G. Orimeier*: This child came to the
office after approximately two weeks with what
I thought was an upper respiratory infection.
What finally brought her in was that she com-
plained that her knees and hips were sore. She
wouldn’t stand up. When placed on her feet she
would keep her knees and hips flexed at about
45° like she was squatting and she wouldn’t get
out of that position. She had a little rash around
^General Practitioner — Sioux Valley Hospital.
— 47
SOUTH DAKOTA
the face, chest, and back when I saw her. We
obtained throat cultures thinking this might be
a poststreptococcal syndrome. We hospitalized
her and gave her aspirin and two days of bed
rest. She seemed to improve so I sent her home.
Eight days later she was back with the same
complaints. It was pretty obvious by this time
that this was a little more than a poststrepto-
coccal syndrome.
Dr. W. Anderson**: To me this case was most
confusing and most interesting in that I have
never had occasion to see a case of derma-
tomyositis where the whole picture from the
very beginning to the fullblown florid condition
developed right under one’s eyes. As Dr. Ort-
meier says, the child originally, as far as we
could determine, complained of pain in her
knees, hips, and elbows. The edema underneath
the eyes was actually a periorbital edema. There
was a little redness. When I originally saw her
in consultation my note was brief but I was
concerned even at that time about the pos-
sibility of dermatomyositis or one of the col-
lagen diseases. However, she did not have any
type of rash on the hands or over the joints.
She was young enough that we could not deter-
mine whether she was complaining of muscle
tenderness or synovial irritation. We just could
not come to a conclusion that it was specific
muscle disease or joint disease. It appeared to
be primary synovial irritation. At one stage
we were concerned whether she might have
a spondylitis because when you tried to arch
her back, she complained bitterly. However
X-rays were negative. Spondylitis may occas-
ionally present like this in a pediatric patient
with low grade fever, irritability, who will com-
plain bitterly when moved. After a number of
weeks calcification may appear on x-rays. This
child did not have a “butterfly” or other rash.
Only on the last admission did the child finally
have considerable edema and muscle weakness.
Of course, she had by then developed dysphagia
which was much more specific. Dr. Delwin
Ohrt* * very wisely on this admission ordered the
enzyme studies which showed the marked crea-
tine phosphokinase elevation. Although I had
thought of a muscle biopsy as the next step, the
marked CPK elevation made it unnecessary.
We also considered a gastrointestinal ulcer.
The reason we thought the hemorrhage might
be from the nasogastric tube was that she had
had the tube in place for a number of days and
**Pediatrician — Sioux Valley Hospital.
* Formerly Intern, presently Resident in Pathology,
Sioux Valley Hospital.
there was bleeding from the nose. When we
pulled the tube the bleeding stopped. We hoped
it might just be irritation. I agree that an ulcer
is a good possibility but we couldn’t do anything
anyway but maintain steroid therapy. The
possibility of trichinosis actually did not cross
my mind: I found no definite muscle tenderness
and there was no eosinophilia.
Dr. Richard Hosen's Diagnoses
1. Dermatomyositis
2. Gastrointestinal ulcer
3. Massive aspiration of gastric contents.
PATHOLOGICAL DISCUSSION
Dr. John F. Barlow: The cause of death was
massive bilateral bronchopneumonia presum-
ably secondary to aspiration of gastric contents.
There was a shallow esophageal ulcer and a
penetrating pyloric ulcer with overlying blood
clot. Whether the ulcer was secondary to steroid
therapy or part of her disease process or both
cannot be determined.
The most striking features of the post-mortem
examination were in the skeletal and esophageal
muscles which were generally atrophic and
Figure I.
Marked atrophy of muscle. Note very little inflamma-
tion is present.
pale. Sections revealed widespread focal areas
of marked muscle fiber degeneration with
vacuolar and granular degeneration as well as
scattered necrotic fibers. There were many
atrophic fibers as well as regenerating fibers.
The grouped atrophy of a neuromuscular atrophy
was not seen and there were normal muscle
fibers — a finding which would be unusual in
muscular dystrophy. In addition, pseudohyper-
trophy, fatty replacement, and central nuclei
were not seen as one might expect in muscular
dystrophy. Primary pathology in the nervous
system was ruled out by normal sections of
— 48 —
MARCH 1967
brain, spinal cord, and peripheral nerves. A
perplexing feature was the lack of significant
inflammation. A few perivascular chronic in-
flammatory cells were present but the marked
inflammatory infiltrate of a polymyositis or
dermatomyositis was not seen. We wondered
whether this might be a case of dermatomyositis
in which the inflammation was modified by
' steriod therapy. We sent the slides to Drs. E, P.
Richardson and Raymond Adams, neuropatho-
logists at the Massachusetts General Hospital
and Harvard Medical School in Boston. They
I thought that the case was polymyositis mod-
i ified by steroids. They commented on the
marked regenerative activity in the muscle
fibers.
This child exhibits a myositis of unknown
etiology which can affect any age group and
Figure II.
One of rare areas of perivascular round cell infiltra-
tion.
Figure III.
Central area of necrosis in center of many atrophic
fibers. The necrotic fibers are pale and stain poorly.
manifest mild to severe symptoms with either
a rapid or prolonged course. Many patients re-
cover completely. Walton and Adams have
made a classification of polymyositis which
points out the variable course and associated
symptoms. The only common features are mus-
cle inflammation and destruction and an un-
known etiology.
Group I —
Acute with or without myoglobinuria
Subacute or chronic — In childhood
In early adult life
In middle or late life “menopausal muscular
dystrophy”
Group II —
Polymyositis with muscular weakness the
dominant feature but with evidence of asso-
ciated connective tissue disease; or dermato-
myositis with severe muscular disability and
often minimal or transient skin changes.
Group III —
Severe connective tissue disease (rheumatoid
arthritis, lupus erythematosus, scleroderma,
rheumatic fever, or a combination thereof)
with relatively slight muscle disability (poly-
myositis) or dermatomyositis with florid skin
changes and muscular disability of secondary
importance.
Group IV—
Polymyositis with carcinoma (carcinomatous
myopathy) or dermatomyositis in association
with malignant disease.
This case might be classified either as poly-
myositis or dermatomyositis depending on how
much clinical involvement of skin would be
necessary for one to call the disease dermato-
myositis. However, as Dr. Hosen pointed out,
this point is academic.
FINAL ANATOMIC DIAGNOSES
1. Polymyositis, modified by steroid therapy.
2. Bronchopneumonia, bilateral
3. Peptic ulcer, pre-pyloric, acute
BIBLIOGRAPHY
1. Adams, Denny-Brown, and Pearson, Diseases of
Muscle, A Study in Pathology, Hoeber Medical
Division, 2nd Edition. 1962.
2. Dowben, R., et al, Polymyositis and Other Re-
lated Muscular Dystrophies, Archives of Internal
Medicine, Vol. 115, May, 1965.
3. Zundel, W. and Tyler, F., The Muscular Dys-
trophies, N.E.J.M., Vol. 273, No. 10, 1965.
4. Nelson, W. E., Textbook of Pediatrics, 8th Edition,
p. 100.
5. Laurin, Carroll A., et al, Canad. M.A.J., 89:1,
288-301, 1963.
6. Most, H., J.A.M.A., 193:11, p. 871-873, 1965.
7. Howell, R. R., Journal of Pediatrics, 68:1, p. 121-
134, 1966.
8. Cook, C. D., et al, Dermatomyositis and Focal
Scleroderma, Pediatric Clinics of North America,
Vol. 10, No. 4, 1963, p. 1001.
— 49 —
Path C APsule
Submitted by the College of American Pathology in
connection with the South Dakota Society of Pathol-
ogists.
THE SCHILLING TEST
FOR PERNICIOUS ANEMIA
The diagnosis of pernicious anemia can be a
difficult problem particularly in patients who
have been treated with Vitamin B12 or folic
acid. Characteristic blood counts can change
quickly after very small amounts of either of
these substances have been administered. In
such patients who also had achlorhydria the
physician has been faced with a real dilemma
and has had two choices: (1) to continue treat-
ment with B12 and assume that the patient
actually has the disease and therefore must be
treated for the remainder of his life, or (2) dis-
continue treatment. In the event he elected to
follow the latter course, several years some-
times elapsed before the patient had unequi-
vocal disease and many patients developed ser-
ious neurological problems.1
It has been shown that B12 will prevent perni-
cious anemia if it can be absorbed through the
intestinal mucosa of the distal ileum. Vitamin
B12 in food or that administered orally will not
be absorbed unless a specific substance, “intrin-
sic factor,” is present. This factor, probably a
mucoprotein,2 is normally secreted by the gas-
tric mucosa and is absent in the atrophic, achlor-
hydric stomach of the patient with pernicious
anemia.3
By using B12 in which the cobalt atom is
radioactive a specific test was developed by
Schilling5 which aids greatly in the diagnosis
of pernicious anemia. Various cobalt isotopes
have been used. The original work was with Co-
balt-60 (C060); currently however, Co57 or
Co58 are favored because their shorter half
lives result in less exposure of the liver to the
effects of radiation.3
Principle of the Schilling Test: Radioactive
B12 is administered by mouth after a 12 hour
fast; immediately thereafter the patient is given
1000 micrograms of ordinary B12 subcutaneously.
This is a “flooding dose”1 and has no actual
effect upon absorption of the radioactive B12.
However, this massive subcutaneous dose blocks
the fixation of the absorbed radioactive B12 by
completely flooding the absorption sites in the
liver. Since the absorption sites are occupied
by the flooding dose, significant amounts of
radioactive B12, which is slowly absorbed over
a 12 hour period, are excreted in the urine. A
24 hour urine specimen is collected and
measured, and an aliquot of this urine is
counted for radioactivity. If 8-10% or more of
the administered radioactivity is recovered in
the 24 hour urine specimen, the results are nor-
mal, and the patient does not have pernicious
anemia. No further tests are needed. However,
if low values (2-5% recovery) are obtained, im-
paired absorption is indicated. The test must
be repeated after 48 hours. With this second
dose of radioactive B12 the patient is given “in-
trinsic factor.” Another 24 hour urine specimen
is collected and measured for radioactivity.
Values of 8% or above in the second test con-
firm the diagnosis of pernicious anemia.4
There are a number of important considera-
tions to remember: (1) the patient must not have
had therapeutic B12 for at least 48 hours before
the test; (2) all urine voided in the 24 hours must
be saved; (3) urine may be preserved with
formalin; (4) radioactive material should not
be given to persons under 18 years of age or to
pregnant women; (5) in severe renal disease it
may be necessary to collect and measure a 48
hour urine specimen; (6) patients with total gas-
trectomy can react to the test in an identical
manner as does the patient with pernicious
anemia; and (7) other disease such as sprue,
“malabsorption syndromes,” celiac disease and
some liver disease may show decreased absorp-
tion of radioactive B12. In these diseases the
results of the second test will also be low be-
cause in none of them is the defect due to in-
adequate “intrinsic factor.”3
REFERENCES
1. Schilling, et al, J. of Lab. & Clin. Med., Vol. 45:-
926, 1955.
2. Wintrobe, Clinical Hematology, 5th Edition, p. 130.
3. Silver, S., Radioactive Isotopes in Medicine &
Biology, 2nd Edition.
4. Levinson and McFate, Clinical Laboratory Diag-
noses, 6th Edition, p. 329.
5. Schilling, R. F., J. of Lab. & Clin. Med. Vol. 42:-
860, 1953.
URINE MICROSCOPY
The microscopic examination of urine for
formed elements is an inseparable part of the
routine urinalysis. Few laboratory procedures
contribute as much pertinent information as
— 50 —
MARCH 1967
a careful study of these urine deposits. As early
as 1870 Beale wrote,1 “By observing [casts] we
are often able to form a correct notion con-
cerning the nature of changes going on in the
tubes at the time the cast was formed.” This
statement is as true today as it was ninety-five
years ago.
THE SPECIMEN
A “clean catch” mid-stream or catheterized
urine, collected in a chemically clean or sterile
container and delivered immediately to the
laboratory is the best possible specimen. The
i very nature of urine collection and exam-
ination makes this specimen extremely sus-
ceptible to contamination and, hence, misin-
terpretation. Labial or vaginal contamination
may introduce large numbers of bacteria or
yeasts, leukocytes, and red blood cells. The first-
voided urine from male and female patients
should be discarded since it may contain large
numbers of bacteria and pus cells whose pres-
ence is due to subclinical urethritis.
THE EXAMINATION
Formerly, simple unstained wet preparations
of urine were examined microscopically. How-
ever, to accurately quantitate and identify renal
casts and cellular elements, the urine must first
be concentrated either by centrifugation or fil-
tration, using the filtrand obtained by drawing
an aliquot of specimen through a membrane
filter. The preparation is then stained with
dilute methylene blue or by the Sternheimer-
Malbin technique2 to aid in differentiating the
casts.
SIGNIFICANCE OF FINDINGS
Casts. Hyaline casts are the most common
casts found in normal urine. Their numbers
may be greatly increased following strenuous
physical exertion or diuretic therapy. They
are composed of homogenous colloidal material,
primarily albumin, and retain the shape of the
tubule lumen in which they were formed.
Greatly increased numbers of hyaline casts ac-
company proteinuria associated with renal fail-
ure of various types; they are also increased in
cardiovascular disease.
Inclusion casts, composed of a hyaline matrix
that traps and retains cellular elements present
in the tubule at the time of cast formation, give
a clearer indication of the cause of renal dis-
ease. Leukocyte inclusions most frequently in-
dicate pyelonephritis and when found contain-
ing coliform bacteria or associated with bac-
terial inclusion casts, they are diagnostic of this
disease. Leukocyte casts may also be present in
glomerulonephritis and related renal disease.
Granular and waxy casts are degenerated leu-
kocyte casts that have remained in the tubule
for some time. They have the same origin as
leukocyte casts and are associated with more
chronic or latent processes. Red cell inclusion
casts indicate renal hematuria and are always
significant. They may be the only manifestation
of acute glomerulonephritis, SBE kidney, renal
infarction or collagen kidney.3
Large numbers of renal epithelial casts in-
dicate increased tubule desquamation due to
nephrotoxins or renal pelvic inflammation.
Occasionally there are a few in normal urine.
Various other inclusions are noted in urine con-
centrates. These include amyloid deposits,
broad hyaline casts and pigments. However,
their significance is not always clear and
further study of the patient is indicated.
Fat bodies and cholesterol esters are occas-
ionally demonstrated in patients with nephrotic
syndrome, lupus, glomerulosclerosis and miliary
infarction. Hyperlipemia is known to increase
the incidence of fatty inclusions.
Cellular elements found in urine most fre-
quently are leukocytes, red cells, epithelial cells
and bacteria. Their significance is directly re-
lated to their numbers since a few are seen in
normal urine. When the number is increased,
their source must always be determined. The
presence of any of these cellular elements with-
in casts always points to the kidney as their
source. White cells, particularly if in clumps,
usually indicate purulent inflammatory pro-
cesses. Red cells may come from any part of the
urinary tract and their presence is particularly
significant in acute glomerulonephritis.
Many kinds of crystals are seen in urine and
are difficult to evaluate. Generally they reflect
urine concentration (oxalates, urates, sodium
chloride) or current sulfonamide therapy.
In summary, the use of staining and concen-
tration procedures rather than the usual micro-
scopic examination of wet sediment makes the
urine microscopic examination a much more
meaningful part of the routine urinalysis. The
detection of cellular elements and renal casts as
occasionally occurs in patients free of symptoms
may provide the most important information
regarding the patient’s renal status.
REFERENCES
1. Beale, L. S. from Schreiner, Arch. Int. Med. 99,
1957.
2. Sternheimer, R. and Malbin, B. Am. J. Med. 9. 1951.
3. Schreiner, G. E. Arch. Int. Med. 99, 1957.
51 —
DEADWOOD DOCTOR
By
Frank S. Howe, M.D.
CHAPTER IX
Conclusion
A Greenhorn Learns
When the influenza epidemic struck the Black
Hills district, I had asked to be accepted into the
Army but on account of the scarcity of phys-
icians in this section, my application was turned
down. For three months during the fall and
early winter of 1918, I had experiences which I
never wish myself or anybody else to have
again. Besides being in charge of the Deadwood
hospital, we put in two emergency hospitals, one
at Nisland where we got beds and used the
school house for a hospital — this was about 30
miles from Deadwood — the other at Newell,
40 miles from Deadwood, where we secured beds
and used the Congregational Church for an
emergency hospital. At one time I had three
assistants and during the rest of the time two.
I stationed one assistant at Nisland where he
was supposed to look after the regular work at
Nisland and Newell. I made night trips to these
points every second day and also made frequent
night calls on families in the intervening terri-
tory. For most of the three months’ period, I
was seeing approximately 100 patients daily.
Those who were very seriously ill in the
emergency hospitals were brought to Deadwood
where many of them had to be operated on for
empyema. At one time I had the entire first
floor of St. Joseph’s Hospital at Deadwood full
of empyema cases that I had operated upon.
During this flu epidemic, practically the only
drug we had was aspirin. In addition to this we
used digitalis, strychnine and other stimulants.
Oxygen was unknown at that time. I remember
well a Slavonian who had pneumonia following
the flu; I saw him in the early evening. I told
the nurse in charge of the floor that when he
died she should call the undertaker but not
under any circumstances to call me as I needed
the rest. At that time I was working 20 to 24
hours a day, usually 24. The temperature was
well toward zero and as this man was fighting
for breath, I threw the window wide open and
put him directly in front of the window where
he got all the oxygen possible. The next day I
asked the nurse what time he died. She said,
“Why, he isn’t dead. He is still alive.” Much
to my surprise this patient lived.
I took advantage of this lesson on the need
of oxygen and wherever I possibly could (in
some cases it was impossible on account of ob-
jection from the families) I opened the windows
wide open and gave them the cold air treat-
ment. I, without any doubt, saved a number of
patients who would otherwise have died. I
remember a Slavonian patient who had the ap-
pearance of being in excellent condition in the
evening when I saw him, although he had flu
pneumonia. He coughed and spit up a large
amount of what we call prune juice sputum.
It looked like pure blood. He took one look at it,
turned over and before morning he was dead.
This patient died prematurely from fright.
I think the most terrible experience I had dur-
ing this epidemic was when I was called to a
house in Sturgis, 14 miles from Deadwood, in
consultation by a doctor there. I found four
patients in a small house. One had probably
less than an hour to live; another one could not
possibly last through the night and a third one
had an empyema which had to be operated on.
We got everything ready and put him on the
kitchen table where the attending physician
gave him the anesthetic and I operated on him.
The patient lived. The other two, of course,
died.
I remember being called to a house near Nis-
land, South Dakota, where I found nine of the
family in bed with flu, all very ill. There was
not only insufficient help to take care of these
people who were ill but there was no help
whatever to take care of the livestock. At no
time during the entire epidemic did I muffle my
phone or take the receiver down. I made pro-
fessional calls during the flu epidemic where I
had long stairs to climb when I would have to
reach down and lift my feet one and then the
other up to the next step. It was the only way
that I could make them obey my will on account
of my extreme exhaustion. I hope that this
country will never again see such an epidemic.
In business I was a mere “babe in the woods.”
At that time Deadwood had a curb exchange
where all of the local mining stocks were posted.
I had a very private inside tip on a mining stock
that was paying dividends. This tip came right
from the general manager, so I bought some of
the stock. The stock kept going down, but I was
told positively that it was only temporary, that
they had some changes to make in the mill, so
I doubled my holdings, getting my stock much
cheaper. I later found that the mine was all
worked out and never did run again. The mill
burned later. I gained some very good exper-
52
MARCH 1967
i ience in that investment because I found out
two things, the first that inside tips aren’t al-
ways so good and second, because a mine is
paying some dividends is no reason to buy the
. stock. I hadn’t been here long at that time.
I remember well my telling Mr. John Hunter,
who later became my father-in-law, about buy-
: ing this dividend paying stock. He said nothing
but I afterwards learned that he was very much
amused. Sometime later Mr. Hunter asked me
if I had any money in the bank; I told him that
I had about $2,100. He said, “That money is
1 earning you nothing and I am paying interest
on money. Why don’t you draw it out, and I will
give you a note for it and pay you 7 per cent
interest the same as I pay at the bank?” I
thought that was a very good idea and as he
asked me to draw it out in currency, I almost
had to force the teller to give it to me. He
thought surely I was going to lose the whole
thing.
When the note became due, Mr. Hunter asked
me how I would like to have some Fish and
Hunter Company stock for the money. I told
him that if he thought it a desirable investment,
it was certainly all right with me. It was years
afterward that I finally came to the conclusion
that first he borrowed this money in fear that I
might find some more mining stocks where I
could lose my money and second, that he ap-
parently wanted to get me interested in Fish
and Hunter Company, of which company I later
became president and still am. Almost every-
thing that I ever learned about business I owe
to the wise advice of Mr. Hunter. The sound
business methods upon which he organized the
Fish and Hunter Company still prevail and are
still sound.
In 1944 after I had been a delegate to the
State Medical Association for a number of years,
I was elected Vice-President and the next year
President-Elect, and the following year, Presi-
dent of the State Association. I had the idea of
having strictly a South Dakota meeting; in other
words, the entire program made up of native
South Dakotans. It may be news to some people
but it is a fact that we had in South Dakota as
native sons many of the outstanding physicians
of the nation. Among others are Dr. Alton
Ochsner of New Orleans, Dr. John Lawrence,
the pioneer in atomic medicine, Dr. Charles
Higgins of the Cleveland Clinic, Dr. Harry
Armstrong, nationally known, particularly for
his work in aviation medicine, Dr. Frederick A.
Coller, head of the Department of Surgery at
the University of Michigan, Dr. Clarence Mills,
Professor of Experimental Medicine at the Uni-
versity of Cincinnati, Dr. Archibald Nissen of
Boston, one of the outstanding leaders in arth-
ritis and related diseases, Dr. George T. Jordan,
eye, ear, nose and throat specialist, formerly
head of the Department at Loyola University at
Chicago. Needless to say, we had a most out-
standing program. For the first time in South
Dakota, we inaugurated the round table dis-
cussions at the noon luncheon, and adopted the
rule of having outstanding men preside at the
different sessions.
I am a life member of the American College
of Surgeons, member of the Academy of Med-
icine, fellow of the American Medical Associa-
tion, am in Who’s Who in Medicine in the North-
west, Who’s Who in Methodism, Who’s Who in
the West by Marquis, a member of the New-
comer Society of America, and of Phi Chi, hon-
orary medical fraternity.
The changes that have taken place in med-
icine and surgery during the fifty years that I
have been in practice are so outstanding that
they are almost unbelievable.
I had been in Deadwood only a short time
when my associate decided to operate on an
acute appendix. It was his first case of the kind.
It fell to my lot to give the anesthetic. At the
time I was supposed to be fairly expert in that
line. The doctor was assisted by the late Dr.
Coburn and after much manipulation, they re-
moved the appendix. I shall never forget Dr.
Moffit’s words as the patient was put on the
cart on the way back to his room. He said,
“From now on, the case is yours,” and it surely
was. I had to take care of this case for months.
He, of course, developed pus. It was a slow pro-
cess but he finally recovered.
My first appendicitis case was a girl with a
ruptured appendix which I operated upon with
fear and trembling. However, she made a good
recovery and as far as I know is still alive. The
modern drugs were entirely unknown. Asepsis
was carried out fairly well by the younger men
but many of the older men and also some nur-
ses, I fear, found it necessary to scratch their
noses about the time they got all scrubbed up.
Even surgical gloves were unknown when I first
started practice. I well remember one of my
teachers, Dr. A. J. Ochsner, saying time and
again, “My assistants must wear gloves. They
do not know how to keep clean. I don’t need
them. I know how to keep clean.”
In spite of the remarkable advances that have
been made in both medicine and surgery, we
still have many difficult problems to solve.
-53 —
SOUTH DAKOTA
These will eventually be solved. I cannot help
but wonder what the next 50 years will pro-
duce in medicine, and just what the span of life
will be after 50 more years of medical and sur-
gical advancement.
W. H. FRITZ, M.D. j
1907—1967
A sudden heart attack claimed the life !
of William H. Frilz, M.D., Mitchell ophthal-
mologist, on January 26, 1967.
He was born November 28, 1907 at Sioux
Falls to Doctor and Mrs. W. H. Fritz, Sr.
He was graduated from Mitchell High
School in 1926, attended the University of
Notre Dame, was graduated from the
school of medicine at Creighton University,
; and did graduate work at Harvard Univer-
sity.
Doctor Fritz was a member of the South
Dakota Medical Association, and was a
past president of the Sixth District Medical
Society.
Survivors include his widow, three sons,
and a daughter. To them we extend our
! deepest sympathy.
Two well-established general practitioners
would like to help third physician interested
in having his own practice. We desire close
association without partnership.
Excellent chance to enjoy the benefits of
solo practice as well as the advantages of
association. No salary or other strings at-
tached.
Potential — Overpowering! New practice
can gross $45,000 to $55,000 within three
years. Population of Sioux Falls 74,000 with
large drawing area. One of the real beauty
spots in the Midwest. Hunting and fishing
year round within an hour’s drive from the
heart of town.
Sioux Falls is fortunate to have two general
hospitals which can accommodate up to about
700 patients. There is also a Veteran’s Hos-
pital, in addition to a Crippled Children’s
Hospital.
Wonderful opportunity for the right man.
If interested, please reply to:
Don R. Salmon, M.D.
504 South Cleveland
Sioux Falls, South Dakota 57103
WANTED: Part-time or full-time positions
for retired physicians. AMA Placement Serv-
ice is compiling a list of available openings
in life insurance companies, V.A. hospitals,
emergency rooms, as consultants at public
hospitals and agencies, voluntary health agen-
cies, developing community health centers, or
school health physicians.
The Placement Service is also interested in
listing all physicians interested in returning
to limited practice or service. This list would
include women physicians not practicing, as
well as retired physicians.
Please forward any information to the
executive office, 711 N. Lake Avenue, Sioux
Falls, South Dakota.
54
THE AMA CONVENTION —
AND WHY WE GO
Buckminster Fuller, the American architect-
engineer-philosopher-poet, has predicted that
education will become the largest and most im-
portant of all industries.
He bases this on a belief that knowledge is the
one resource of man which not only cannot be
depleted, but can, indeed, be consciously in-
creased. In the advanced, automated world of
the near future, he says, “leisure” time gained
from the workaday world through automation
may be spent in the classroom; in fact, people
may be paid to go to school.
Physicians have long understood the value of
knowledge — of education.
We are forever involved in the task of “keep-
ing up” — without pay it may be noted.
There are few physicians who regard the task
as onerous, however. “Keeping up” is part of
being a physician; it is a privilege and a respon-
sibility.
A number of reservoirs of medical informa-
tion may be tapped by the physician. These in-
clude colleagues, medical journals, medical
news publications, continuing education courses,
medical meetings and conventions, drug detail
men, and miscellaneous others.
Every year there is the “big show” where the
physician can tap practically every reservoir:
the Annual Convention of the American Med-
ical Association.
At the 1966 Annual Convention about 600
scientific papers were presented, and nearly 300
scientific exhibits were on display as well as
hundreds of industrial exhibits.
No other medical meeting in the world
matches the range of subjects presented, from
reviews of general medicine to experimental
medicine and therapeutics.
The 116th Annual Convention of the American
Medical Association will be held in Atlantic City
June 18-22 this year. Convention Hall and sur-
rounding hotels will house the Scientific Pro-
gram; the House of Delegates will meet at the
Chalfonte-Haddon Hall Hotel.
Among special presentations planned are four
general scientific sessions on backache, healing,
patient care, and sex.
The 22 Scientific Sections will offer programs
individually, and many will hold joint meetings
on subjects of common interest. A full schedule
of medical motion pictures is planned. At least
five color telecasts will be broadcast, live from a
Philadelphia hospital in cooperation with the
University of Pennsylvania School of Medicine.
If knowledge is a resource, as Buckminster
Fuller says it is, the AMA Annual Convention
is surely a mother lode.
55 —
The State Legislative Session has just adjourned, and a record number of bills were con-
sidered which did have, or could have had a definite impact on medicine in South Dakota.
I believe this points up the fact that we, as physicians, must continue to be aware of the
political issues both at the state and national level.
We can no longer afford to sit back and watch, but rather we must become involved, even to
the point of running for office if one is so inclined.
Preston Brogdon, M.D.
President of the South Dakota State
Medical Association
— 56 —
~fkU iJ ifcuf
MEDICAL ASSOCIATION
News Notes • Changes • Births • News
Pop's Proverb
Beautiful phraseology
never excused an error.
C. Rodney Siollz, M.D.,
Watertown, was one of four
private practitioners to par-
ticipate in a postgraduate
conference on obstetrics and
gynecology at the University
of Iowa medical school in
January.
Obstetrical management of
the diabetic, induced labor and
family planning were among
the subjects taken up at the
conference.
❖ ^ ❖
One of the two new direc-
tors of Valley National Bank
in Sioux Falls is W. A. Arne-
son, M.D. Dr. Arneson was so
named at the recent annual
meeting of the bank.
$ ^ $
Chester A. Clark, M.D.,
assistant director of Home-
stake’s medical department in
Lead, South Dakota, has an-
nounced his retirement. Dr.
Clark joined the Homestake
staff in 1952.
He will be replaced by
Layne E. Carson, M.D.
^ ^ ^
A Watertown physician was
the recipient of the “Boss of
the Year” award presented by
the Watertown Jaycees. The
physician so honored was
G. Robert Bartron, M.D.
Several South Dakota phys-
icians recently attended a
week-long general practice re-
view held at the University of
Colorado Medical Center in
Denver.
Doctor C. Wesley Eisele,
associate dean of postgraduate
education, directed the inten-
sive review, which on succes-
sive days covered the fields of
internal medicine, pediatrics,
surgery, trauma, obstetrics,
gynecology, and dermatology.
Among those attending from
South Dakota were Theodore
R. Jacobson, M.D., Hot
Springs; M. A. Marousek,
M.D., Belle Fourche; N. J.
S u n d e t , M.D. and L. P.
Swisher, M.D., Kadoka.
YOUR
CONTRIBUTION
TO THE
SOUTH DAKOTA
MEDICAL SCHOOL
ENDOWMENT
FUND
IS NEEDED
NEW OFFICERS
NAMED
Election of officers has been
held by most of the District
Medical Societies. Results re-
ceived to date are as follows:
DISTRICT 2
President —
E. H. Heinrichs, M.D.,
Watertown
Vice President —
A. K. Brevik, M.D.,
Watertown
Secretary-Treasurer
T. J. Wrage, M.D.,
Watertown
DISTRICT 3
President —
R. G. Belatti, M.D.,
Madison
Vice President —
R. E. Shaskey, M.D.,
Brookings
Secretary-Treasurer
C. M. Kershner, M.D.,
Brookings
DISTRICT 4
President —
S. B. Simon, M.D.,
Pierre
Vice President —
E. H. Collins, M.D.,
Gettysburg
Secretary-Treasurer
J. T. Cowan, M.D.,
Pierre
DISTRICT 5
President —
Clifford Lardinois, Sr.,
M.D.. Huron
Vice President —
Guillermo Huet, M.D.,
Huron
Secretary-Treasurer
William O. Hanson, M.D.,
Huron
DISTRICT 9
President —
T R. Jacobson, M.D ,
Hot Springs
Vice President —
J. M. Hewitt, M.D.,
Rapid City
Secretary-Treasurer
H. O. Haugan, M.D.,
Rapid City
— 57
SOUTH DAKOTA
ANNOUNCEMENT
Children’s Hospital, Denver,
is holding its Spring Clinics at
Vail on June 26, 27, 28, 1967.
Guest Faculty: Sydney Gellis,
M.D., Tufts University; Mary
Ellen Avery, M.D., Johns Hop-
kins University; Robert Kugel,
M.D., University of Nebraska;
James K. Weaver, M.D., Uni-
versity of New Mexico; Wil-
liam Daeschner, M.D., Univer-
sity of Texas; Hugh Thomp-
son, M.D., Tucson, District
Chairman of Region VIII of
the Academy of Pediatrics.
Morning seminars and lec-
tures. Afternoons of leisure in
the Rocky Mountains. Ad-
vances in Pediatrics and The
Path Ahead in Pediatric Prac-
tice will be the guidelines for
the Clinics.
FEE $40.00. WRITE: Joseph
Butterfield, M.D., Children’s
Hospital, Nineteenth Avenue
at Downing, Denver, Colorado
80218.
Mrs. James S. Lydiatl, wife
of James Lydiatl, M.D.# Hot
Springs, was named official
Miss South Dakota chaperon
at a recent meeting of the
Miss South Dakota Pageant
board of directors. Her ap-
pointment was part of the pre-
liminary plans being made for
the event set for June 24-25
this year in Hot Springs.
Mother of three girls and
one boy, Mrs. Lydiatt has
worked with the pageant cor-
poration as local chaperon and
in other capacities. Her job as
official chaperon will begin
right after the pageant and in-
volves accompanying the new
Miss South Dakota to Atlantic
City for the Miss America
Pageant.
^
DR. HAYES
COMES HOME
Robert H. Hayes, M.D., Win-
ner, South Dakota, has re-
turned from Viet Nam. Dr.
Hayes left last January for
duty with the U. S. Public
Health Service in Viet Nam
and arrived in Saigon on Jan-
uary 6, 1966.
Upon his return to the
United States, he and his fam-
ily spent a few days in Wash-
ington, D. C., during which
time they visited with Rep.
E. Y. Berry.
^ ^ ^
HURON M.D.
RECEIVES HONOR
W. H. Saxton, M.D., des-
cribed as a “doctor of med-
icine, service, leadership and
character,” was presented the
Citizen of the Year award at
the annual meeting of the
Huron Chamber of Com-
merce.
Dr. Saxton was co-founder
of the Huron Clinic and has
practiced medicine there since
that time. He is also past
president of the South Dakota
Medical Association, member
of the American College of
Surgeons and of the American
College of Obstetrics and
Gynecology.
Togetherness....
...can be rough when epidemics of nausea and
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free from toxicity1 or side effects2 3 and will not mask symptoms of
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O
RORER
E
R
1. Bradley, J. E., et al.\ J. Pediat. 38:41 (Jan.) 1951.
2. Bradley, J. E.: Mod. Med. 20:71 (Oct. 15) 1952.
3. Crunden, A. B., Jr., and Davis, W. A.: Am. J. Obst.
& Gynec. 65:311 (Feb.) 1953.
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32.4 mg. caffeine.
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ANNUAL MEETING — SOUTH DAKOTA STATE MEDICAL ASSOCIATION
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when it counts...
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THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
Volume XX April, 1967 Number 4
CONTENTS
Trends in Medical Education and Care and the
University of South Dakota School of Medicine 25
George W. Knabe, Jr., M.D.
On the Profession of Medicine 30
Glenn W. Geelhoed
Hypofibrinogenemia: Its Diagnosis and Treatment
in the Obstetric Patient 34
Joseph S. Betts, M.D.
The Case Against Anti-Smoking Campaigns in the Public Schools . . 41
Albert R. Allen, M.D.; Loxi M. Allen, B.S.
Clinicopathological Conference — Sioux Valley Hospital .... 48
James A. Rud, M.D.; Michael R. Ferrell, M.D.
Preventable and Avoidable Cancers and
Cancers Arising from Personal Indifference 62
Wendell G. Scott, M.D.
Commentary from The School of Medicine,
University of South Dakota 69
Charles R. Gaush, Ph.D.
Minutes of the Council Meeting 72
PathCAPsule 80
Editorial 84
President’s Page 87
This Is Your Medical Association 88
Second Class Postage Paid at Sioux Falls, South Dakota
Published monthly by the South Dakota Medical Association, Publication Office
711 North Lake Avenue, Sioux Falls, South Dakota 57104
usually gram
(initial adult dose)
Indications: Urinary tract infections caused by gram-negative and some gram-
positive organisms.
Side effects: Mainly mild, transient gastrointestinal disturbances; in
occasional instances, drowsiness, fatigue, pruritus, rash, urticaria, mild
eosinophilia, reversible subjective visual disturbances (overbrightness of
lights, change in visual color perception, difficulty in focusing, decrease in
visual acuity and double vision), and reversible photosensitivity reactions.
Marked overdosage, coupled with certain predisposing factors, has produced
brief convulsions in a few patients.
Precautions: As with all new drugs, blood and liver function tests are advis-
able during prolonged treatment. Pending further experience, like most
chemotherapeutic agents, this drug should not be given in the first trimester
of pregnancy. It must be used cautiously in patients with liver disease or
severe impairment of kidney function. Because photosensitivity reactions have
occurred in a small number of cases, patients should be cautioned to avoid
unnecessary exposure to direct sunlight while receiving NegGram, and if a
reaction occurs, therapy should be discontinued. The dosage recommended
for adults and children should not arbitrarily be doubled unless under the
careful supervision of a physician. Bacterial resistance may develop.
When testing the urine for glucose in patients receiving NegGram, Clinistix®
Reagent Strips or Tes-Tape® should be used since other reagents give a
false-positive reaction.
Dosage: Adults: Four Gm. daily by mouth (2 Caplets® of 500 mg. four times
daily) for one to two weeks. Thereafter, if prolonged treatment is indicated,
the dosage may be reduced to two Gm. daily. Children may be given
approximately 25 mg. per pound of body weight per day, administered in
divided doses. The dosage recommended above for adults and children
should not arbitrarily be doubled unless under the careful supervision of a
physician. Until further experience is gained, infants under 1 month
should not be treated with the drug.
How supplied: Buff-colored, scored Caplets® of 500 mg. for adults, conve-
niently available in bottles of 56 (sufficient for one full week of therapy) and in
bottles of 1000. 250 mg. for children, available in bottles of 56 and 1000.
References: (1) Based on 23 clinical papers, 1512 cases. Bibliography on
request. (2) Bush, I. M., Orkin, L. A., and Winter, J. W., in Sylvester, J. C.:
Antimicrobial Agents and Chemotherapy — 1964, Ann Arbor, American
Society for Microbiology, 1965, p. 722.
\m/7f/?rop
Winthrop Laboratories, New York, N. Y. 10016
NegGram
Brand of
lidixic ■ . d
a specific anti-gram-negative
eradicates most urinary
tract infections...
• Low incidence of untoward effects; no fungal
overgrowth, crystalluria, ototoxic or nephrotoxic
effects have been observed.
• “Excellent” or “good” response reported in
more than 2 out of 3 patients with either chronic
or acute gram-negative infections.1
*As many as 9 out of 10 urinary tract infections are now caused
by gram-negative organisms: E. coli, Klebsiella, Aerobacter,
Proteus, Paracolon or Pseudomonas2. . . However, infections of the
urethra and prostate caused by non-gonococcal gram-negative
organisms are believed to be less prevalent.
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
SUBSCRIPTION $2.00 PER YEAR
SINGLE COPY 20c
Volume XX
April, 1967
Number 4
STAFF
Editor . Robert Van Demark, M.D.
Assistant Editor Judith Perkins Schlosser _
Associate Editor Robert Thompson, M.D
Associate Editor Gordon Paulson, M.D
Associate Editor Geraid Tracy, M.D
Business Manager t Richard C. Erickson
Sioux Falls, S. D.
Sioux Falls, S. D.
Yankton, S. D.
Rapid City, S. D.
Watertown, S. D.
Sioux Falls, S. D.
EDITORIAL COMMITTEE
R. E. Van Demark, M.D., Chr. Sioux Falls, S. D.
J. A. Anderson, M.D. Madison, S. D.
G. E. Tracy, M.D. Watertown, S. D.
W. R. J. Kilpatric, M.D. Huron, S. D.
Hugo Andre, M.D Vermillion, S. D.
H. B. Munson, M.D. Rapid City, S. D.
R. F. Thompson, M.D. Yankton, S. D.
John B. Gregg, M.D. Sioux Falls, S. D.
PUBLICATIONS COMMITTEE
R. E. Van Demark, M.D., Gordon Paulson, M.D., Robert Thompson, M.D., W. T. Sweeney,
M.D.
OFFICERS
South Dakota State Medical Association
President
President-Elect
Vice-President
Secretary-Treasurer
Executive Secretary
Delegate to A.M.A.
Alternate Delegate to A.M.A
Chairman Council
Speaker of The House
Sioux Valley Medical Association
President _ C. J. McDonald, M.D
Secretary Daniel Youngblade, M.D.
Treasurer Karl Wegner, M.D.
P. Preston Brogdon, M.D.
John Stransky, M.D.
J. T. Elston, M.D.
A. P. Reding, M.D
Richard C. Erickson
A. P. Reding, M.D.
R. H. Quinn, M.D.
E. T. Lietzke, M.D.
J. P. Steele, M.D. ..
Mitchell, S. D.
_ Watertown, S. D.
Rapid City, S. D.
Marion, S. D.
Sioux Falls, S. D.
Marion, S. D.
Sioux Falls, S. D.
Beresford, S. D.
Yankton, S.D.
Sioux Falls, S. D
Sioux City, Iowa
Sioux Falls, S. D.
TRENDS IN MEDICAL EDUCATION AND CARE AND THE
UNIVERSITY OF SOUTH DAKOTA
SCHOOL OF MEDICINE
George W. Knabe, Jr., M.D.*
Public concern with health is greater now
than ever before. There are expectations that
more medical care of all types will become
readily available and at reasonable cost. Gov-
ernment programs to provide this have been in-
itiated, although the medical resources neces-
sary for their implementation are presently in-
adequate. In the past few years a number of
comprehensive studies have been undertaken
to determine how physicians should be educa-
ted and trained and how medical care can be
most effectively delivered. To evaluate the in-
ternship and the residency the American Medi-
cal Association created a Citizen’s Commission
on Graduate Medical Education with John S.
Millis, Ph.D., President of Western Reserve Uni-
versity, as chairman.1 The Ad Hoc Committee
on Education for Family Practice was similarly
appointed by the A.M.A. to examine the prob-
lems and issues involved in preparing physici-
ans for general or family practice.2 The Cogge-
shall Report, “Planning for Medical Progress
Through Education,” offered suggestions for
courses of action to meet anticipated needs of
America for medical education and also spoke
of the future role of the Association of Ameri-
can Medical Colleges, which sponsored the
study.3 These reports and others provided con-
siderable material for discussion at the 63rd An-
nual Congress on Medical Education convened
by the AMA in Chicago February 10 to 14, 1967.
It is clear that significant changes in medical
education and practice are occurring and that
more will come as a result of recommendations
being made. The Citizen’s Commission was dis-
turbed by the lack of coordinated supervision
of various phases of medical training, citing the
fact that medical schools provide undergradu-
ate education, hospitals control the internship
* School of Medicine, University of South Dakota,
Vermillion.
and the specialty boards dictate the manner of
residency training. It, therefore, advocated that
there be a new Commission on Graduate Medi-
cal Education to specifically plan, coordinate
and review standards for medical training. It
also recommended that the internship be aband-
oned and that this phase of training be incor-
porated into the residency or included in medi-
cal school. Most of these studies of medical
practice stress the need for more “family phys-
icians” and urge medical schools to develop
special courses and programs in community
medicine or family practice.
New medical schools are being constructed
and old ones expanded to meet the need for
medical manpower. Numerous experiments with
curricula are being conducted. Some institutions
have followed the lead of Western Reserve Uni-
versity in adopting an interdepartmental ap-
proach wherein medical school departments, in-
stead of offering separate courses of their own,
participate in multidiscipline courses designed
around systems of the body or disease processes.
A number of schools are combining the pre-
medical and medical years into a six year con-
tinuum, often introducing basic science courses
into the premedical years. There is also a ten-
dency toward advancement of substantial clin-
ical instruction into the freshman and sopho-
more medical school years. A popular innova-
tion is the “core curriculum” which consists of
certain basic required courses in each year of
school which do not, however, occupy the en-
tire time. The student is then free to select ad-
ditional courses appropriate to the type of med-
ical career he desires to follow, be it family
medicine, specialty practice, research, teaching,
administration or a combination of these. This
is part of a trend toward individualization of
medical education.
These developments have implications for our
school. From the time the University of South
25 —
SOUTH DAKOTA
Dakota School of Medicine was established in
1907, it has been dedicated to educating students
in the basic medical sciences of anatomy, bio-
chemistry, microbiology, physiology, pharma-
cology, and pathology; and has provided intro-
ductory courses in physical diagnosis and clini-
cal medicine. An integral part of the educational
effort has been medical research which has con-
tributed to the advancement of knowledge and
the development of teachers and investigators.
Services to the state have included postgradu-
ate education for physicians and auxiliary medi-
cal personnel. Also, faculty have provided con-
sultation in their special fields of competence.
There has been little or no involvement in pa-
tient care or health programs since the school
lacks the full-time clinical staff and facilities to
service such activities.
The medical school has been an asset to the
state, providing South Dakota and other stu-
dents a professional career opportunity which
otherwise might be denied them. Its graduates
have performed creditably in the four-year
schools where they have completed their edu-
cation, and a significant number have returned
to practice in South Dakota. However, the edu-
cational program has been hampered by chronic
deficiencies of staff and facilities which become
more serious each year. The Joint Accreditation
Committee of the Council on Medical Education
of the AMA and the Association of American
Medical Colleges called attention to these at the
time of its survey in 1963, stating that salary
scales “are critically low and great staffing diffi-
culties may be anticipated in the future if this is
not corrected.” Nationwide medical school sal-
ary surveys still show South Dakota near or at
the bottom. Dr. Walter L. Hard, former Dean,
called attention to the grave nature of these
problems in his letter to the editor in the Oc-
tober, 1966 issue of this Journal.
Medical schools all over are assuming central
roles in health planning and service. Surgeon
General William H. Stewart has urged they
make a stronger commitment to the problems
of the community and that programs of teach-
ing, research and transfer of knowledge be fully
relevant to the real health needs of the people
served. Our two-year school must also respond
to social change and public demand. Participa-
tion of the medical school is essential, for ex-
ample, in the Regional Heart Disease, Cancer &
Stroke Program in which education of physi-
cians is an important aspect. It should also play
an important role in the Comprehensive Health
Planning Program of 1966 (Public Law 89-749)
devoted to marshalling health resources in the
state. Competence to deal with these and other
new responsibilities must be developed without
compromising the basic mission of teaching and
research. This means expansion of clinical ac-
tivities, including creation of a division of com-
munity medicine or state health services. There
should also be greater collaboration between the
school and the State Health Department, state
health planning agencies and voluntary health
organizations. In view of the rapid growth of
allied health professions, the University of
South Dakota needs to work with other state
institutions to develop more and better pro-
grams to provide urgently needed paramedical
personnel. Continuing education can now pro-
ceed on a larger scale than before thanks to ad-
vances in educational technology, including tele-
vision now used advantageously in basic medi-
cal science instruction. Liaison with South Da-
kota State University in the field of veterinary
medicine should be explored. Because of the
kinship of animal and human diseases, research
collaboration here could be profitable; and much
veterinary material could be used in teaching
of medical students.
With all of this in prospect, one naturally
wonders about the feasibility of a four-year
medical program being established. It should be
noted that all of the newly developing schools
plan to eventually offer a full four-year curric-
ulum. The Association of American Medical
Colleges estimated that in 1985 there will be 110
four-year schools instead of the present 84; but
that there will be only 3 two-year schools, ap-
parently the same three which exist today. Or-
ganization of new basic science schools is evi-
dently not being recommended. The Coggeshall
Report, for example, finds no justification for
establishing more of them. It explains that be-
cause basic sciences and clinical instruction and
their respective faculties are becoming more
intimate and intertwined it is impossible to
maintain continuity when the educational pro-
gram is split between two schools.
Proposals for a four-year medical school in
South Dakota have not met with success in the
past. The expense of operation and the lack of an
adequate source of patients for teaching have
been cited as major deterrents. Perhaps equally
important has been a lack of accurate informa-
tion about the real requirements for such a pro-
gram and of a coordinated and directed effort
to promote it. In any case, while a four-year
school may not have been feasible in the past
there are pressures growing which may force
— 26 —
APRIL 1967
the school to lengthen its program in the near
future. For instance, problems are being created
by innovations in curricula in schools where our
students complete their training, and it will
soon be impossible for them to transfer to some
of these schools. Of course, a transfer arrange-
ment could be made with one or several four-
year schools wherein our curriculum is tailored
to their requirements. This might, however,
have the effect of making our institution sub-
ordinate to one of another state.
If a four-year medical program is established
in South Dakota, it will probably not be entire-
ly in the form of the traditional large new build-
ing with university hospital attached. A teach-
ing hospital administered by the university
would seem essential but it need not be large.
Perhaps an arrangement with presently affili-
ated hospitals might increase the teaching cap-
acity. There is also the possibility of the state
adopting the “university without walls” con-
cept, as in Indiana, with creation of clinical
teaching units in medical centers about the
state to provide the third and fourth year in-
struction. An advantage in this would be that
the centers could also offer postgraduate medi-
cal education and could assist in carrying out
certain state and federal health service activi-
ties. An entirely different approach would be
to utilize the Indian population for teaching.
There is no reason why some imaginative alli-
ance with the U.S. Public Health Service could
not be developed whereby the educational needs
of a medical school could be met while at the
same time medical care for the Indian was im-
proved. Under such a program, some medical
students might choose public health careers, a
thought which should appeal to the Public
Health Service. Still another suggestion, made
in the 1966 State Legislature, is to explore the
practicability of establishing a regional medical
school for the states of South and North Dakota,
Montana, and Wyoming.
It may be that the wisest approach will be to
build a four-year medical program gradually,
adding to the present school certain clinical
instructional and health service units as they
are needed and can be supported. It should be
emphasized that no four-year program should
be attempted without first greatly strengthen-
ing the present school of basic medical sciences.
Careful and detailed planning for the future is
essential. In view of today’s rapidly changing
patterns of medical education and health care,
South Dakota must engage now in serious and
continuing study of how to support and best mo-
bilize its educational resources to meet the pub-
lic needs and demands.
REFERENCES
1. The Graduate Education of Physicians, The Re-
port of the Citizen’s Commission on Graduate
Medical Education, Chicago: American Medical
Association, September 1966.
2. Meeting the Challenge of Family Practice, The
Report of the Ad Hoc Committee on Education for
Family Practice, Chicago: American Medical As-
sociation, September 1966.
3. Coggeshall, L. T.: Planning for Medical Progress
Through Education, Association of American Med-
ical Colleges, April 1965.
4. Hard, W. L.: Letter to the Editor, S. D. Jl. Med.,
19: 47, 49, Oct. 1966.
— 27 —
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I
ON THE PROFESSION OF MEDICINE
Glenn W. Geelhoed
University of Michigan
Medical School
June 1, 1966
Prize Winning Essay
Norman A. Welch, M.D.
Medical Ethics Essay Contest
1966
What does it mean to follow a profession?
Medicine is widely called a profession, yet the
term profession connotes several different
meanings. It would be interesting to note what
meanings the term has and in what senses they
are applied to medicine. I should like to anal-
yze and describe four uses of the term profes-
sion and examine implications the applicable
meanings have for the ethics of the medical
profession.
First of all, the term profession can mean the
following of an occupation as a means of liveli-
hood or for gain. In this sense a profession is
simply a means for making a living. Uses of
the term in this sense are common, as in a pro-
fessional pugilist, or a professional driver who
makes a living by driving a truck. That there
is nothing innately noble about the term pro-
fession when so used is seen in its use to de-
scribe criminals, such as a professional safe-
cracker. Another example can be noted in its
application to certain women who are said to
practice the “world’s oldest profession.”
The word professional can also imply a cer-
tain expert mastery or competence in almost
any field. There it is used as the opposite of
“amateur.” The popular advertising motto “the
best is always pro” is an illustration of the term
in this sense. A combination of special abilities
is implicit in this sense of the word and stand-
ards of behavior and achievement are concomit-
ant features. Several professions by the first
criterion of the term “means for making a liv-
ing” have acquired a subspecialized meaning in
the second sense of the term by superimposing
the adjective “learned.” The “learned” profes-
sions have an inherent set of requirements that
place them beyond the practice of anyone who
might wish to make a living by them. There is
also a recognized method for achieving the
skills or knowledge that set professions apart
from other occupations. No qualitative differ-
ence has separated the second sense from the
first, but merely a quantitative level of know-
how.
A third sense in which the term profession is
used involves following as a business an occu-
pation ordinarily engaged in as a pastime, or
making a business of an office not properly to be
regarded as a business. Examples of the former
would be golf, ski, chess, or tennis pros; an ex-
ample of the latter would be a “professional pol-
itician.” In the former case there is a note of
dilettantism, a “playing at” an occupation as
though it were a hobby in which one had ac-
quired sufficient proficiency to warrant pay-
ment. The latter case evinces a betrayal of a
trust, a taking advantage of a responsibility to
one’s own profit.
And last, there is the sense of the term pro-
fession that means a calling, an avowal or dec-
laration that one “stands for something.” The
“professor” is a defender of principles to which
he adheres. The term profession is used in reli-
gion to refer to that outward declaration of a
faith in doctrine and ideals, using the term in
this same sense.
Of these four meanings, which applies to the
profession of medicine? Since almost all phys-
icians depend upon the practice of their art for
their livelihood, medicine is a profession in the
first sense. As in the other crafts and trades
included in the first sense, the physician makes
a living by offering his commodity of medical
service as an item of exchange. Unlike the ma-
jority of the crafts which are its fellows under
the first criterion, medicine is a profession that
commands more than a living; it has a high re-
turn value that is often the first thing that
strikes the eye of the young aspirant. The re-
— 30 —
APRIL 1967
spect and reward that are given to the doctor
as artisan (cf. der Arzi) may be due to the de-
mand and value of his commodity as estimated
by the consumer, or it may follow additionally
from the higher requirement levels seen under
the second sense of the term profession.
By the second criterion, medicine is indeed
a learned profession, and one that requires a
specialized expertness of no mean achievement.
This refinement of the profession is but a quan-
titative step above the first level; however, the
division is not a qualitative one but merely a
measure of cleverness. A technician can func-
tion at whatever level he seeks, since there is
no morality that necessarily advances with the
sophistication of technology. There are techni-
cians (who are professional in both first and
second senses) in medicine who wash glassware,
technicians who draw blood, and some who re-
move appendices, all within the same spectrum
of measured skill.
The third sense of the term profession enters
into the consideration of those who consider a
profession “the gentlemanly thing to do.” A pro-
fession in this third sense is what one follows
to avoid doing manual labor, and offers the dil-
ettante a respectable perch from which to view
the world and select items for smattering. A
popular version of this among young physicians
is medical gamesmanship. More despicable than
those who play at medicine are those who play
it for their own advantage and enjoy the pecu-
liar type of power with which physicians are
entrusted.
It is only when we reach the fourth and last
sense of the term profession that we face what
it is that medicine stands for. A hard look at
the practice of medicine while standing upon
this highest rung of the ladder in the definition
of their profession may convince many physi-
cians that they do not have a profession in this
final sense, for in medicine what is to profess?
If medicine be a calling, to what are we called?
For the ethical standards and goals medicine
professes, some knowledge of the historical heri-
tage that has contributed to the profession in
this peculiar sense is necessary.
One of the earliest and still most articulate
examples of the qualities that constitute the
true profession of medicine is found in a Socra-
tic dialogue in Plato’s The Republic. Thrasy-
machus is inquiring into reasons why it is that
men work. He has just decided that all men, in-
cluding the ruler in even the ideal state, would
be motivated only by self-interest in the power
that would accrue to the person in the profes-
sion and in the living he would make. Socrates
stops him short:
“Enough of this banter . . . Tell me this:
Is the physician of whom you spoke as be-
ing strictly a physician, a maker of money,
or a healer of the sick? Take care you speak
of the genuine physician.”
“A healer of the sick,” replied Thrasy-
machus.
But, Socrates now asks, aren’t you neglecting
the fact that each of the individuals who prac-
tices medicine has a primary interest in making
a living, as in the first sense of the term pro-
fession?
“Has not each of these persons an inter-
est of his own?”
“Certainly.”
“And is it not the proper end of their
art to seek and procure what is for the in-
terest of each of them?”
“It is.”
Through further questions, Socrates develops
an alternative thesis that the goal of medicine
is in the practice of it; that the refinement and
expertness of the art is the goal to be pursued
and enjoyed as an end in itself. Taking pleasure
in the expertness of medical practice would
qualify it as a profession in the second sense of
the term. Or ars gratia artium might be the
self-sustaining energy loop that would justify
medicine’s definition as a profession to the
casual practitioner who is seeking a profession
in the third sense.
“Have the arts severally any other inter-
est to pursue than their own highest per-
fection?”
“What does your question mean?”
“Why, if you were to ask me whether it
is sufficient for a man’s body to be a body,
or whether it stands in need of something
additional, I should say, certainly it does.
To this fact the discovery of the healing
art is due, because the body is defective,
and it is not enough for it to be a body.
Therefore, the art of healing has been put
in requisition to procure what the interests
of the body require. Should I be right, think
you, in so expressing myself, or not?”
“You would be right.”
“Well then, is the art of healing itself
defective, or does any art whatever re-
quire a certain additional virtue; as eyes
require sight, and ears hearing, so that
these organs need a certain art which shall
investigate and provide what is conducive
to these ends: is there, I ask, any defective-
SOUTH DAKOTA
ness in an art as such, so that every art
should require another art to consider its
interests, and this other provisional art a
third, with a similar function, and so on,
without limit? Or will it investigate its own
interest?” . . .
“Apparently it is so,” he replied.
“Then the art of healing does not consider
the interest of the art of healing, but the
interest of the body.”
“Yes.”
Since it appears that our limitation of the
profession of medicine to any of the first three
senses of the term is no longer tenable, for what
good does medicine stand?
“Well, but you will grant, Thrasymachus,
that an art governs and is stronger than that
of which it is the art.”
Thrasymachus assented with great re-
luctance to this proposition.
“Then no science investigates or enjoins
the interest of the stronger, but the inter-
est of the weaker, its subject.”
To this also he at last assented, though
he attempted to show fight about it.
“Then is it not also true, that no phy-
sician, insofar as he is a physician, con-
siders or enjoins what is for the physician’s
interest, but that all seek the good of their
patients? For we have agreed that a phy-
sician strictly so called, is a ruler of bodies,
and not a maker of money; have we not?”
Thrasymachus agreed that we had.
Socrates concludes with the ethical principle
that has dominated the subsequent tradition of
medicine. We distinguish man qua wage-earner
from man qua professor of medicine. Only in
the fourth sense of the term does medicine rise
to a truly noble profession. And what is the
good that medicine professes? The good of its
objects which are other than they who prac-
tice the art and which is external to the art it-
self. And what are the objects of medicine’s
service? The patients, the society, in a word —
man.
“And thus, Thrasymachus, all who are
in any place of command, insofar as they
are rulers, neither consider nor enjoin their
own interest, but that of the subjects for
whom they exercise their craft: and in all
that they do or say, they act with an ex-
clusive view to them, and to what is good
and proper for them."
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Merck Chemicals are distributed by QUINTON COMPANY, Division of MERCK & CO., INC., Rahway, N. J.
Hypofibrinogenemia:
Its Diagnosis and Treatment
In the Obstetric Patient
By Joseph S. Belts, M.D.
Ann Arbor/Fori Meade, Maryland
Hemorrhage during pregnancy continues to
be a major cause of fetal and maternal morbid-
ity and mortality, but until comparatively re-
cently the importance of aberrations in the clot-
ting mechanism was not recognized as a factor
in serious obstetric hemorrhage. The literature,
however, now contains many reports of the var-
ious bleeding diatheses which develop in con-
junction with certain obstetric complications.
3,4,5
The most common and important of these is
fibrinopenia. Explanations for the reduction in
available fibrinogen during pregnancy have
been discussed. In brief, the entrance of throm-
boplastin, or a thromboplastin-like substance,
from necrotic decidua at the placental site or
from amniotic fluid into the maternal circula-
tion is presumed to be the basic cause. Throm-
boplastin unites with maternal fibrinogen to
form fibrin which is deposited in small vessels
throughout the circulatory system. If the infus-
ion of thromboplastin continues, all the avail-
able fibrinogen may be utilized, and a signifi-
cant disposition to hemorrhage is created.
Russell1 in 1959 stressed that the successful
management of acute hemorrhage in obstetric
patients requires a rapid, orderly and systematic
sequence of procedures. He designed a flow
sheet to help accomplish this in obstetric coagu-
lation problems.
The purpose of this discussion will be: (a) to
enumerate the pregnancy complications most of-
ten associated with hypofibrinogenemia; (b) to
discuss the clinical evaluation of fibrinogen lev-
els; (c) to survey our experience with hypofib-
rinogenemia in the Department of Obstetrics
Doctor Betts, associated with the Department of Ob-
stetrics and Gynecology at the University of Michi-
gan School of Medicine, is now with the Kimbrough
Army Hospital, Fort George G. Meade, Maryland.
Reprinted with permission from Michigan Medicine,
September, 1966.
and Gynecology at the University of Michigan
during the eight-year period, 1956-64; and (d) to
suggest a protocol for management of patients
with the complications responsible for hypofib-
rinogenemia.
The obstetric complications most often associ-
ated with hypofibrinogenemia are abruptio pla-
centae, intrauterine fetal death during the sec-
ond trimester of pregnancy (particularly if the
baby died from erythroblastosis fetalis)2 and
amniotic fluid infusion. The latter is a rare, but
often fatal complication.
At the Sloane Hospital for Women 12 per cent
of the cases of hypofibrinogenemia followed
postpartum hemorrhage. Hypofibrinogenemia
also may develop in women with placenta pre-
via, placenta previa accreta, intrauterine infec-
tion, after injection of certain abortifacients in-
to the uterus (especially liquid soap), with hyda-
tidiform mole, after Cesarean section, and even
after normal vaginal delivery.
EVALUATION OF LEVEL OF FIBRINOGEN
The normal range of fibrinogen during the
last few weeks of pregnancy is 300-600 mg per
100 ml of whole blood. Any level below 100 mg
per cent may be associated with a hemorrhagic
diathesis. There are four methods by which the
fibrinogen level can be determined. All of these
tests are valuable; some fit specific clinical cir-
cumstances better than others.
Clot Observation Test: Clot observation is a
simple qualitative test which can be performed
in any hospital. The main defect in this test is
that it does not detect minor changes. A five
milliliter sample of blood is placed in a test
tube and observed for clotting. Under normal
conditions a clot forms within six minutes and
retracts to 30-40 per cent of the original volume
in one hour. The clot is firm and withstands
shaking. If the blood fails to clot within six min-
34
APRIL 1967
utes, or if the clot that does form is soft and
subsequently disintegrates, the clotting mech-
anism is defective.
If a stable clot forms in less than six minutes,
the fibrinogen level is probably greater than 150
mg per cent. If a clot fails to form within 30
minutes, the level is less than 100 mg per cent.
A fragile clot which fails to retract is evidence
of a reduction in fibrinogen, but the exact level
cannot be determined by this test.
Proper management of all medical emergencies requires preparation prior to the emergency. This ar-
ticle completely discusses the diagnosis and treatment of the obstetrical catastrophies most commonly compli-
cated by hypofibrinogenemia. Emphasis is placed upon having an orderly preconceived plan for manage-
ment of these complications. Several case reports are included from the experience of the Department of Ob-
stetrics and Gynecology at the University of Michigan Medical Center.
Fibrindex Test: The Fibrindex test* is simple
to perform and interpret. Fifty units of throm-
bin are mixed with 1 ml of oxalated blood and
observed for clotting. In contrast to the clot ob-
servation test, any clot formation within one
minute after mixing indicates that the patient
has a fibrinogen level of at least 100 mg per cent.
If there is no clot formation in one minute, the
test is said to be positive; the fibrinogen level is
below 100 mg per cent. This test is always run
in parallel with the blood of a normal pregnant
patient which serves as a control. Because the
Fibrindex test may be done rapidly, and because
it has a definite endpoint, it is more useful in
an emergency than the clot observation test.
Quantitative Fibrinogen Level: Neither the
clot observation test nor the Fibrindex test
measures actual plasma fibrinogen levels, so
neither can be used to measure changes in fib-
rinogen concentration over a period of time
which would permit us to anticipate clotting ab-
normalities before they actually develop. Both
the quantitative fibrinogen level and the fibrin
titre technique described by Schneider7 can be
utilized for this. The quantitative fibrinogen le-
vel is complicated, taking at least an hour to
run, and few hospitals are able to do it on either
a serial (several on one case) or emergency
(night or weekend) basis.
Fibrin Titre Technique: The fibrin titre tech-
nique (Table I) is a simple serial dilution of
whole blood with thrombin added as a catalyst.
The dilutions are so adjusted that each dilution
correlates with milligrams per cent of fibrino-
gen in whole blood. If clotting occurs through
the fifth tube, the titre is 1:200 and the patient
has at least 200 mg per cent fibrinogen, but less
than 400 mg per cent, and so on. This test can
be performed easily, with results available in
20 minutes. The semiquantitative fibrin titre is
the best test available for serial evaluation of
fibrinogen levels in an acute situation when the
development of hypofibrinogenemia might be
anticipated.
*Fibrindex — Ortho Pharmaceutical Corporation,
Raritan, New Jersey.
UNIVERSITY OF MICHIGAN EXPERIENCE
(1956-1964)
Between January 1, 1956, and December 30,
1963, 14,000 women were delivered in the Wo-
men’s Hospital of the University of Michigan
Medical Center and hypofibrinogenemia was di-
agnosed ten times. Hypofibrinogenemia was rec-
ognized in nine women with severe abruptio
placentae and in one with an intrauterine fetal
death. Two other patients, one with amniotic
fluid infusion and another with postpartum
hemorrhage from uterine atony, were delivered
elsewhere and transferred to the medical center
for treatment of the complication.
The clinical course of each of these 12 pa-
tients is summarized in Table II. Case summar-
ies of patients with abruptio placentae, intra-
uterine fetal death, postpartum hemorrhage,
and the amniotic fluid infusion syndrome are
presented, and a protocol for management of
these obstetric complications is suggested.
TABLE I.
Fibrin Titre Technique
Rapid, semiquantitative fibrin determin-
ation.
Rack of Kahn tubes, (1 ml) tuberculin sy-
ringe, Topical thrombin solution (20 units
thrombin per drop of 50% glycerol- water
solution), and Ringer’s solution.
(1) Place Ringer’s solution in tubes: #1
tube — 0 ml; 22 tube — 3 ml; #3 tube — 4
ml; and 1 ml to each of the others up
to a total of 8 tubes.
(2) Draw 1 ml blood with tuberculin syr-
inge.
(3) Place 0.5 ml blood in first tube.
(4) Place 0.5 ml blood in tube 22, mix and
transfer 1 ml to tube 23, mix and
transfer 1 ml to next tube; repeat with
each succeeding tube.
(5) Add 20 units (1 drop) topical throm-
bin to each tube and tilt each once.
(6) Read titre in 15-30 minutes. Dilutions
are 1:10, 1:50, 1:100; 1:200; 1:400; 1:800;
and 1:1600.
Titre values of 50, 100, 200, etc., correlate
fairly well with mg per 100 ml of plasma.
ABRUPTIO PLACENTAE
Case Summary: G.B. 265643, age 21, Caucas-
ian, Gravida 3, Para 2, type O Rh negative, was
admitted at term soon after she was awakened
by severe abdominal pain and moderate bright
Purpose:
Materials
Method:
Reading:
— 35 —
SOUTH DAKOTA
vaginal bleeding. Her blood pressure on admis-
sion was 90/60, the pulse rate was 120/minute,
and fetal heart sounds could not be heard. The
blood pressure dropped to 40/0 but, responded
to intravenous saline, Trendelenburg position
and blood transfusions. The urine was clear
yellow with 1+ protein reaction. A fibrin titre
was positive at 1:400. Palpation of the abdomen
revealed a rigid, irritable, tender uterus. The
cervix was soft, 2 cm dilated and the head was
at station — 3. The membranes were artificially
ruptured.
During the next two hours, the patient was
given 2000 ml of whole blood. There was little
visible bleeding, but the pulse remained above
100 and the blood pressure about 90/60. The
fibrin titre dropped progressively to 1:50 and
she was given a rapid intravenous infusion of
6 gm of fibrinogen. Since labor had not pro-
gressed, she was delivered of a 7 lb. stillborn
male infant by Cesarean section. The placenta
had separated completely. Because of continued
depression of the titre (1:100) and bleeding, the
patient was given 2 more gm of fibrinogen after
which recovery was uneventful.
Management of Severe Abruptio Placentae:
The clinical diagnosis of acute severe abruptio
placentae is generally made on the basis of ab-
dominal pain associated with a tender, irritable,
sometimes rigid uterus in the third trimester
of pregnancy, with or without bright red vagi-
nal bleeding.
The infant usually dies shortly after the pla-
centa separates, but the inability to hear the
heart sounds is not definite proof of fetal death.
A fetal electrocardiogram may be helpful in de-
termining whether the infant is alive. The ex-
amination should not be performed until the
condition of the mother has been assessed and
her treatment started.
The first step in the management of a patient
suspected of having premature placental separ-
ation is to draw blood for hematocrit, cross-
match and clotting studies. Blood loss can be
massive (greater than 3000 ml), and one must
be prepared to administer large quantities of
blood rapidly. An intravenous infusion of saline
is started through a 15 gauge needle or a large
cannula which is inserted when blood is drawn
for preliminary laboratory examinations.
Sterile vaginal examination is performed to
determine fetal position and the status of the
cervix. The membranes are artificially rup-
tured to induce or stimulate labor and also in an
attempt to diminish thromboplastin dissemina-
tion into the circulation. Presumably, evacua-
tion of amniotic fluid effectively compresses re-
troplacental sinusoids and therefore reduces the
rate at which thromboplastin from the necrotic
decidua and retroplacental clot enters the ma-
ternal circulation. The membranes should usu-
ally be ruptured even though the conditions are
unfavorable by the usual criteria. An indwell-
ing Foley catheter is placed in the bladder in
order to permit periodic determination of urin-
ary output.
Table III presents an outline for the manage-
ment of abruptio placentae. If delivery is not
imminent, the fetal heart sounds are normal,
and the pregnancy is of at least 35 weeks’ dura-
TABLE II.
Blood
Type
Therapy
Outcome
Pat’t Age
G/P
Gestation
Complication
ABO RH
Fibrinogen
Bid.
Fibgn.
Delivery
Fetal
Maternal
938215
D.M.
24
1/0
37
weeks
Abruptio
Placentae
O
Pos.
Fibrindex
90 mg. %
2
U
6 gm.
Vaginal
Stillbirth
Good
604633
B.D.
25
3/2
36
weeks
Abruptio
Placentae
O
Pos.
Fibrindex
2
U
6 gm.
Vaginal
Stillbirth
Good
908910
P.V.
21
2/1
39
weeks
Abruptio
Placentae
A
Neg.
Fibrindex
80 mg. %
2
U
6 gm.
Vaginal
Stillbirth
Good
296200
V.L.
23
4/3
33
weeks
Abruptio
Placentae
A
Neg.
“No Clot”
7
u
6 gm.
C/S
Stillbirth
Good
285865
C.L.
22
3/2
34
weeks
Abruptio
Placentae
A
Neg.
Titre
1:10
5
u
3 gm.
C/S
Stillbirth
Good
265643
G.B.
21
3/2
39
weeks
Abruptio
Placentae
O
Neg.
Titre
1:10
5
u
8 gm.
C/S
Stillbirth
Good
992877
E.S.
39
2/1
38
weeks
Abruptio
Placentae
B
Neg.
“No Clot”
0
0
C/S
Good
Good
038088
R.H.
30
2/0
40
weeks
Abruptio
Placentae
AB
Neg.
Titre
1:100
70 mg. %
2
u
0
C/S
Good
Good
944804
A.G.
25
2/1
28
weeks
Intrauterine
Fetal Death
O
Neg.
90 mg. %
0
0
Vaginal
Stillbirth
Good
597991
D.C.
47
8/7
40
weeks
Abruptio
Placentae
O
Pos.
“No Clot”
8
u
6 gm.
Vaginal
Fair
Good
458820
B.R.
29
1/0
40
weeks
PPH from
Uterine Atony
O
Neg.
Fibrindex
16
u
5 gm.
Vaginal
Good
Good
047793
E.M.
43
8/7
43
weeks
Amniotic Fluid
Embolism
AB
Pos.
“No Clot”
6
u
6 gm.
Vaginal
Poor
Fatal
— 36 —
APRIL 1967
TABLE III.
Abruplio Placentae
Third Trimester Management
Diagnosis Is Made by:
Initial Management:
Plan for Delivery:
Abdominal Pain
Rupture Membranes
VAGINAL DELIVERY
Fetus Alive
Progressive Labor
Minimal Clotting Derangement
Replaceable Bleeding
Stable Vital Signs
Fetus Dead
Tender Irritable
Fibrindex Followed
Progressive Labor
Correctable Clotting Derangement
Replaceable Bleeding
Uterus
By Serial Titres
CESAREAN SECTION
Vaginal Bleeding
Blood Transfusion
Fetus Alive
If Indicated
Poor Labor
Progressive Fall in Titres
Continued Bleeding
Fetus Dead
Poor Labor
Progressive Fall in Fibrinogen
Titre
Fibrinogen ^ 100 mg. %
Profuse Bleeding
tion, an immediate Cesarean section is indicat-
ed in the interest of the baby. If the heart sounds
are irregular, or if there is question as to the
condition of the infant, emergency Cesarean sec-
tion should usually not be done because the in-
fant will either be born dead or may have suf-
fered extensive damage from anoxia.
If the uterus is tender and rigid and the fetus
is dead, blood transfusion is indicated even
though there has been little visible bleeding. As
much as 3000 ml of blood can be concealed with-
in the uterus, and if one waits for evidence of
shock before starting transfusion, a coagulation
defect, renal failure, or even death may result.
Initially 1000 ml of whole blood, plus an amount
equal to the visible blood loss is administered.
Thereafter, blood replacement is based on the
patient’s vital signs, the amount of external
bleeding, serial hematocrits and blood volume
studies.
As the blood transfusion is being started, 8
gm of fibrinogen should be obtained and the
diluent warmed to room temperature. The op-
erating room must be notified that there is
a possibility of an emergency Cesarean section.
An anesthetist should be available.
If the Fibr index test is negative (normal clot-
ting), a quantitative test for fibrinogen should
be ordered because the actual concentration
may be considerably reduced even though the
Fibrindex test indicates normal clotting. Fibrin-
ogen determinations should usually be repeated,
even though the initial reading is normal, be-
cause the concentration is likely to fall progres-
sively until the uterus is emptied.
Labor may begin promptly and terminate ra-
pidly after artificial rupture of the membranes,
but if it does not, oxytocin stimulation should be
considered. Stimulation should be carefully
monitored since uterine response may be un-
predictable. However, effective labor can usual-
ly be induced even though massive myometrial
hemorrhage has occurred. If the vital signs can
be kept stable by transfusion and if the hemo-
static mechanism remains intact, it is safe to
observe closely and await vaginal delivery.
Cesarean section is indicated when delivery
does not appear to be imminent and any of the
following are present: an abnormal clotting
mechanism, continued bleeding requiring trans-
fusion, or a progressive fall in blood fibrinogen
levels. If the level is above 100 mg per cent
when the operation is performed, it usually is
not necessary to give additional fibrinogen. If
the level is less than 100 mg per cent, however,
6 gm of fibrinogen should be administered im-
mediately prior to operation.
If one elects to replace fibrinogen and await
delivery, the fibrinogen level must be checked
at least every two hours. Dysfunctional labor is
a contraindication to vaginal delivery unless it
responds promptly to oxytocin stimulation. A
long time lapse may necessitate the injection of
large amounts of fibrinogen, with the real dan-
ger of subsequent serum hepatitis if the patient
survives. In addition, hemorrhage into vital or-
gans, especially the brain, with extensive de-
struction of irreplaceable tissue, may occur un-
less the coagulation defect is corrected. After
37
SOUTH DAKOTA
the placenta is removed, the liver rapidly re-
plenishes fibrinogen at the rate of about 350 mg
per hour.
INTRAUTERINE FETAL DEATH
Case Summary: A.G. 944804, age 25, Caucas-
ian, Gravida 2, Para 1, type O Rh negative, had
an initial Rh anti D indirect Coombs antibody
titre of 1:2048. She also had overt diabetes which
had become manifest during this pregnancy.
The values of a glucose tolerance test were fast-
ing blood sugar 100 mg per cent and two hour
200 mg per cent. Her first infant had died in
utero at the 37th week of pregnancy. During this
pregnancy, fetal heart tones were never heard
after the 24th week. Repeated quantitative fib-
rinogen determinations demonstrated a drop
from 190 mg per cent at the 26th week to 90 mg
per cent at the time of delivery at the 28th
week. However, there was no excessive bleed-
ing and no replacement was necessary.
Management of Intrauterine Fetal Death: Fe-
tal death in utero in the first trimester of preg-
nancy is rarely complicated by clotting abnor-
malities. However, hypofibrinogenemia devel-
ops in one-third of patients if fetal death occurs
after the 16th week and the products are re-
tained longer than four weeks.2
Dilation and curettage has been our usual
management of missed early abortion if the pro-
ducts are not expelled spontaneously. Before the
curettage is carried out, the patient’s clotting
status must be assessed by measuring the fibrin-
ogen concentration and bleeding, clotting and
prothrombin times.8 If no clotting abnormality
is apparent, then the procedure can usually be
carried out with safety. 1000 ml of fresh whole
blood and 8 gm of fibrinogen should be in the
operating room before the procedure is begun.
The accepted management of late intrauterine
fetal death has been observation until the spon-
taneous onset of labor. Until recently, there has
been no safe method of inducing labor in these
cases. Now, in properly selected cases, we can
induce labor, with relative safety, by injection
of a hypertonic salt solution into the amniotic
sac. When a late intrauterine fetal death has oc-
curred, we assess the clotting mechanism each
week. We induce labor with intra-amniotic hy-
pertonic saline if it does not occur spontaneous-
ly after three weeks of fetal death.
If a clotting defect is discovered, it must be
corrected before any procedures to empty the
uterus are attempted.
POSTPARTUM HEMORRHAGE
Case Summary: B.R. 058820, age 29, Caucas-
ian, Gravida 1, Para 0, type O Rh negative, de-
livered a healthy term infant in another hos-
pital after an uncomplicated antenatal course
and a two-hour labor. She immediately began to
bleed profusely, presumably from an atonic
uterus and two vaginal lacerations. After 10
units of blood had been administered, her blood
failed to clot and a Fibrindex test showed a co-
agulation defect. Two grams of fibrinogen were
administered, and the uterus was removed. Dur-
ing the operation, she was given more blood and
fibrinogen because of bleeding from the ped-
icles. Postoperatively, she developed pulmon-
ary edema and renal failure and was trans-
ferred to the University of Michigan Medical
Center where she developed a pelvic abscess,
sacral palsy and pyelonephritis from which she
was recovering when she was discharged nine
weeks after delivery.
Management of Postpartum Hemorrhage:
Postpartum hemorrhage occurs frequently, and
its treatment is well outlined in standard ob-
stetric texts. The hemorrhage can usually be
controlled by evacuating the uterine contents,
massage, uterine elevation and oxytocics. Con-
tinued bleeding indicates the need for re-exam-
ination in search of an overlooked uterine, cervi-
cal or vaginal laceration. Blood loss must be re-
placed immediately to avoid permanent damage
of vital organ systems.
Hypofibrinogenemia may develop if the hem-
orrhage is severe and is a result of intravascu-
lar coagulation or because of activation of a fib-
rinolytic system. The fibrinogen level should be
checked if hemorrhage cannot be controlled by
the usual measures. If the level is found to be
100 mg per cent or less, then 4 gm of fibrinogen
should be infused.
Large doses of intravenous oxytocics, com-
bined with vigorous massage and parametrial
compression, will usually control the bleeding.
If it continues despite these measures and the
clotting status is normal or corrected to nor-
mal, then an immediate laparotomy with bilat-
eral hypogastric ligation and/or hysterectomy
should be carried out.
AMNIOTIC FLUID INFUSION
Case Summary: E.M. 047793, age 43, Caucas-
ian, Gravida 8, Para 7, type AB Rh positive,
was admitted to another hospital for elective in-
duction of labor at 43 weeks of pregnancy. Soon
after the membranes were artificially ruptured
and oxytocin was begun, the patient became
dyspneic and cyanotic. The blood pressure could
not be obtained and she soon became comatose.
After two hours, during which blood pressure
was maintained with vasopressors, she deliv-
— 38 —
APRIL 1967
ered an 11-pound stillborn infant. Immediately
after the delivery of the placenta, she had a
massive hemorrhage of blood which did not
clot. The patient was still comatose and had de-
veloped a hemiparesis. After receiving multi-
ple transfusions, vasopressors, fluids and 6 gm
of fibrinogen, she was transferred to the Uni-
versity of Michigan Medical Center where short-
ly after arrival she died. An autopsy was per-
formed, and the primary pathological diagnosis
was amniotic fluid infusion.
Management of Amniotic Infusion Syndrome:
Fortunately, this syndrome is rare. About 25
per cent of patients who develop it expire be-
fore any treatment can be instituted, and in
those who survive the diagnosis cannot be prov-
en. The clinical picture is thought to be due to
a combination of sudden mechanical blockade
of the pulmonary vascular tree and an anaphyl-
actoid reaction to particulate material in amni-
otic fluid.6
The typical case occurs in an elderly multi-
para who delivers a large baby after a rapid
labor. She suddenly, and without apparent rea-
son, develops acute respiratory distress and a
shock-like state. The differential diagnosis in-
cludes other forms of embolism, ruptured uter-
us with hemorrhagic shock, aspiration of vomit-
us, eclampsia, idiosyncrasy to anesthetic drug,
cerebral vascular accident, acute pulmonary ed-
ema and spontaneous pneumothorax. If the am-
niotic infusion syndrome is suspected, a multi-
ple treatment program should be instituted im-
mediately. Oxygen with 1 per cent isuprel is
administered with positive pressure which will
help counteract anoxia as well as bronchio-
spasm and pulmonary arteriolar spasm. Atro-
pine Sulfate 0.4 mg intravenously will inhibit
the reflex vagal tone, and ephedrine sulfate 25
mg intravenously will help maintain systemic
blood pressure without constricting the pulmon-
ary vasculature. Solu-Cortef 1.0 gm given intra-
venously will inhibit the anaphylactoid reaction.
Rotating tourniquets should be used to help di-
minish right heart strain. Also, an intravenous
digitalis preparation is started.
A large proportion of those who survive amni-
otic fluid infusion for more than one hour will
develop hypofibrinogenemia and will hemorr-
hage from the placental site. Therefore, the fi-
brinogen concentration should be determined at
20-minute intervals, and fibrinogen adminis-
tered if the level falls to 100 mg per cent or low-
er.
Lost blood must be replaced with fresh whole
blood, taking care not to overload the cardiopul-
monary circulation. A careful record of all
treatment should be kept on a separate page of
the patient’s chart, especially in the first hour
or two after the initial insult.
SUMMARY
The problem of managing acute hemorrhage
in the obstetric patient presents a challenge to
every physician. This paper stresses the need
to suspect the presence of a coagulation defect
in these patients. Means for clinically evalua-
ting the clotting mechanism have been outlined.
Management has been suggested for hypofibrin-
ogenemia with abruptio placentae, postpartum
hemorrhage, intrauterine fetal death and the
amniotic infusion syndrome.
REFERENCES
1. Caillouette, J. C., Longo, L. D., and Russell, K.
P.: Flow sheet for use in obstetric complications.
J.A.M.A., 170:1520, 1959.
2. Goldstein, D. P., Johnson, J. P., and Reid, D. E.:
Management of intrauterine fetal death. Obstet.
Gynec., 21:523, 1963.
3. Phillips, L. L.: Unexpected cases of hypofibrino-
genemia. Amer. J. Obstet. Gynec., 84:429, 1962.
4. Reid, D. E., and Weiner, A. E.: Coagulation deaths
with intrauterine fetal death from RH isosensitiza-
tion. Amer. J. Obstet. Gynec., 60:1015, 1950.
5. Reid, D. E., and Weiner, A. E.: Intravascular clot-
ting and afibrinogenemia, the presumptive lethal
factors in the syndrome of amniotic fluid embol-
ism. Amer. J. Obstet. Gynec., 66:465, 1953.
6. Russell, W. S., and Jones, W. N.: Amniotic fluid
embolism. Obstet. Gynec., 26:476, 1965.
7. Schneider, C. L.: Rapid estimation of plasma fibri-
nogen concentration and its use as a guide to ther-
apy of intravascular defibrination. Amer. J. Obstet.
Gynec., 64:141, 1952.
8. Spraitz, A. F., Jr., Welch, J. S., and Wilson, R. B.:
Missed abortion. Obst. Gynec., 87:877, 1963.
9. Weingold, A. B., Seigal, S., and Stone, M. L.: Intra-
amniotic hypertonic solutions for induction of la-
bor. Obstet. Gynec., 26:622, 1965.
-39-
40
S.D.J.O.M. APRIL 1967 - ADV.
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PLUS SIMETHICONE—
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THE FACTOR WHICH
ANTACIDS ALONE
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of liquid contains: magnesium hydroxide, 200 mg.; aluminum hydrox-
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teaspoonfuls of liquid to be taken between meals and at bedtime.
The Stuart Company, Pasadena, California
Division of Atlas Chemical Industries, Inc.
Stuart
THE CASE AGAINST ANTI-SMOKING CAMPAIGNS IN
THE PUBLIC SCHOOLS
By
Albert R. Allen, M.D., Selah, Washington
Loxi M. Allen, B.S., Selah, Washington
Smoking habits of students through high
school have been determined in many areas by
means of questionnaires, and the results in Se-
lah, Washington, are very similar to those
found in Portland, (Oregon)3, Newton, (Mas-
sachusetts)78, Winnipeg, (Canada)6, Maine1’5,
etc. Cigarette smoking has been judged as the
largest single cause of preventable disease in
the United States today and it seems logical to
try to educate students to keep them from start-
ing the habit, and if they have already started,
then to educate them to stop.
Following is a partial list of the types of ed-
ucational programs which have been tried in
various parts of the world: 1. In Utah, juvenile
smokers go to court under a 1907 law which
makes it illegal for a person under 21 to have,
use, or accept tobacco. It is also illegal to sell
or give tobacco to persons under 21. 2. Den-
mark’s poster campaigns warn of the perils of
teen-age smoking and stress the economic fac-
tors of how much sooner they can own motor
scooters if they do not smoke. 3. An extensive
anti-smoking program is being prepared by
Canadians. 4. In an anti-smoking campaign in
Edinburgh, Scotland2, the only change noted
was that more people thought that it was un-
desirable for young people to start smoking.
5. In Maine 15, an education program among
high school students conducted by the Health
Department, using material from the American
Cancer Society, showed only a slight change of
attitude toward smoking, but no discernible
change in smoking habits of students. In fact,
the numbers of students smoking increased, as
did the amount they smoked. 6. In Mamaroneck,
New York9, a student non-smoking committee
has been formed to educate the other students
regarding the hazards of smoking. Members of
this committee have reported: that “ — by the
time the students are in high school, it is too
late to change habits because many are already
hooked. Even in junior high we often find it
is too late. We’ve found our campaign is most
effective in the elementary school where pupils
are more open-minded and impressionable.”
Education programs of many types have been
tried throughout the world but few have been
evaluated to see if they have had any effect.
Such an evaluation of an education program was
done in Selah Public Schools.
MATERIAL AND METHOD
A survey of the smoking habits of students
in Selah schools, grades six through twelve, was
done in 1961, 1962 and in 1964. In the beginning,
a film strip describing the relationship between
cigarettes and lung cancer was shown to all
students. Literature from the American Cancer
Society and other sources was made available
to junior high and high school students. An es-
say contest on “Smoking and your Health” was
held in both schools with two separate sets of
three cash awards offered to the three winning
essays. Shortly after the winners were an-
nounced, the 1961 survey was conducted. The
results of this survey were compiled from the
information on 801 completed forms. I also tried
to ascertain their attitude toward smoking, us-
ing a questionnaire prepared and supplied by
the American Cancer Society. See Table I Male
and Female.
In the Portland schools, it was found that
students who belonged to the Honor Society and
those who engaged in organized school activ-
ities had a lower incidence of smoking. Because
of this, a second survey was conducted in Selah
among the Honor society, Lettermen and Vi-
kings (a service club) to see how many students
in these clubs smoke. The Honor Society had
the lowest incidence.
In 1961, the 11th grade boys had the highest
incidence of smoking in the school, 41%, and
when the school activities chart is checked only
two are members of the Honor Society, five
41 —
SOUTH DAKOTA
had won their letters in sports and only one is
a member of Viking Club. The results of all of
the Iowa Basic tests given to each class in high
school show that the 1961 11th grade class, as
a group, had much lower average scores than
the other three classes, yet their average I.Q.
is almost the same.
In 1962 the information obtained from the
1961 survey was shown to the students stressing
the facts that the smoking students do not com-
pete successfully academically or in athletics,
nor do they participate in service clubs and
other school activities. I felt that the “scare
technique” of “If you smoke for 35 to 40 years,
one in ten of you will have lung cancer” was
too remote to the teenage students to affect
them appreciably. I wanted to offer a possible
reward that could be obtained within a period
of a few months to a maximum of three years
to see if the possibility of academic, athletic
and social success in high school might influ-
ence students to refrain from smoking, and en-
courage those who were smoking to stop. In the
1962 survey the same questionnaire was filled
out resulting in 775 completed forms. The clubs
were listed at the bottom of the original ques-
tionnaire with the request that the students
check the clubs to which they belonged. More
than twice the number of students indicated
that they belonged in Honor Society or were
Lettermen than were actually registered in
these clubs. Furthermore, most of them indi-
cated that they were smokers, so a second ques-
tionnaire was necessary in order to obtain reas-
onably accurate information, and this form was
distributed only to actual members of the clubs.
Because the Winnipeg survey covered grades
5 through 12, the 5th grade was also surveyed
in 1962. One 5th grade teacher felt that the sur-
vey was a waste of his time so all of his class
filled in every space on the questionnaire. The
teacher was a non-smoker. This points out how
a few students can change results but an un-
cooperative teacher can invalidate the results
in any grade. It also points out the difficulties
of re-surveying a school since both teachers and
students can vary the results quite markedly
when they know what information is wanted.
The Selah high school teachers observed that
most of the students who smoked were taking
vocational rather than academic subjects as was
noted in the Portland survey. The Winnipeg
and Selah surveys show similar areas where
the incidence of smoking increases in the ju-
nior high 7th and 8th grades with some decrease
in the 9th and 10th grades. It was obvious, after
the 1962 survey, that the early smoker is also
the early drop-out. This is seen clearly in the
comparison between the girls who were in the
8th grade in 1961, who became 9th graders in
1962. All the regular smokers were no longer
present. They had dropped out of school. A sim-
ilar drop-out pattern is found among male
smokers when they reach the age of 16. Few
realize that the incidence of smoking is greater
among 8th grade students than it is in the first
year of high school.
It is interesting to observe the change in at-
titude among the students. In the sixth grade,
opinion is strongly against smoking but by the
time they finish the eighth grade smoking is an
accepted habit. Table II shows the attitude
scores for each grade, both boys and girls, with 5
as a figure to represent strong opinion against
smoking and 0 to represent strong opinion for
it. The attitude changes in favor of smoking
from 3.7 in the 1961 6th grade girls to 3.3 in the
7th grade, to 2.9 in the 8th grade girls, then up
to 3.1 in the 9th grade. When the 6th grade
girls of 1961 were compared with the 7th grade
girls of 1962, bearing in mind that this is the
same group of girls, their attitude has changed
from 3.7 to 3.3 indicating more approval of
smoking — this is the same as between the 6th
and 7th grade girls in 1961. This seems to be
very similar for both boys and girls in all grades
surveyed, however the higher the incidence of
smoking the lower the average attitude score.
There is a consistently greater number of
boys than girls smoking and the amount they
smoke is also consistently greater. In both
groups the number who have never tried smok-
ing decreases rapidly, with the lowest being
among the 8th grade boys 1962 where only 16%
have not tried. There were, however, several
notes on the questionnaires, voluntarily written
by those who had tried smoking, indicating that
they had done so in the 4th grade. In discussion
with the principals of the schools, their main
difficulties with smoking, i.e. hiding of cigar-
ettes, smoking on the school grounds etc. starts
in the 4th grade and there is good indication
that some children start to smoke, with paren-
tal approval, even before this time.
In February, 1964, the same questionnaires
were used, about six weeks after the Surgeon
General’s Committee Report on Smoking was
released. This survey, resulting in 959 completed
forms, was conducted without any previous
warning or additional education attempt on my
part. In the 6th, 7th, and 8th grades, that group
of students who had the least exposure to our
42
APRIL 1967
TABLE I
MALE
A. Smoke V2 pack or more daily
B. Smoke regularly but less than V2 pack daily
C. Smoke at least once a week
D. Have tried smoking, but not as much as
one day a week
E3
uzx
E. Never smoked at all
Completed
Questionnaires
6th Grade
1961 1962 1964
1
m
1
i
I
A
I
§
38%
37%
58%
61 43 65
7th Grade
1961 1962 1964
9th Grade
10th Grade
11th Grade
8th Grade
1961 1962 1964
75 74 68
12th Grade
1961 1962 1964
42 41 57
— 43 —
TABLE I
SOUTH DAKOTA
FEMALE
A. Smoke V2 pack or more daily
B. Smoke regularly but less than V2 pack daily
C. Smoke at least once a week
D. Have tried smoking, but not as much as
one day a week
E. Never smoked at all
6th Grade
1961
/ / /
1962
777
1
1964
777
f.
a
f / /
(IL
■V
72%
65%
74%-
Completed
Questionnaires
78
62
68
Ed
1X3
tZZ!
7th Grade 8th Grade
1961 1962 1964 1961 1962 1964
9th Grade
10th Grade
11th Grade
12th Grade
44 —
APRIL 1967
TABLE II
AVERAGE SMOKING ATTITUDE
0. strongly in favor of smoking (unfavorable
attitude)
5. strongly opposed to smoking (favorable
attitude)
MALE FEMALE
Grades 1961 Grades
6th.
7th.
8th.
9th.
10th.
11th.
12th.
0.
6th.
7th.
8th.
9th.
10th.
11th.
12th.
1.
2.
3.
3.4 —
"3^
" 2.9
3.1
2.9
3.1
4.
3.7^
"1h3
3.1
3.2^
5.
1962
0.
1.
2.
2.9
2.9
3.1
2.9
2.^
'll
3.
■S-3
2.9
3.0
3.0
3X
4.
3£^
sO.Z
'^Zl'
5.
1964
— 45 —
SOUTH DAKOTA
previous educational programs, the incidence of
smoking among boys and girls was markedly
less than it was in the 1961 and 1962 surveys. In
contrast, those students who were in 6th, 7th
and 8th grades in 1961 showed a marked in-
crease in the numbers who were smoking or
who tried smoking in 1962. Of the 7th grade
boys in 1961, 48% had not yet tried smoking.
When these same boys were 8th graders in 1962
only 16% had not tried to smoke. In 1964, when
these boys were in the 10th grade there are 29%
who have not tried smoking. Why this discrep-
ancy? I contacted the school authorities and
found that there were 152 8th grade graduates
in 1962, and of these, 27 are not now in the Selah
High School, but there are 36 students in the
Sophomore class who were not attending Selah
schools at the time of the 8th grade graduation.
In Selah, the majority of drop-outs occur by
the end of the Sophomore year, and, assuming
that this is true, the majority of those students
who transferred in are probably not smokers.
There are two entirely different reasons why
young people start and continue to smoke4. A
Harvard study7’8 indicates that the flaw in anti-
smoking campaigns directed exclusively at teen-
agers is that they start smoking because of the
influence of their parents and peers, particular-
ly the older siblings in the family. Their survey
considered a smoker to be anyone who had
smoked 10 cigarettes. It does not require many
cigarettes to make one addicted to nicotine, the
socially accepted tranquilizer. The Harvard
Survey showed that in all grades, the mean in-
telligence levels of children who did not smoke
were higher than those of students who did
smoke. Among smokers, mean I.Q.’s were lower
for the heavy smokers than for the light smok-
ers. Mean achievement in the academic years
preceding the survey was substantially higher
for non-smokers and for light smokers than for
heavy smokers. These differences were particu-
larly striking among boys. Higher academic
achievement for non-smokers was evident with-
in all social classes but the incidence of smok-
ing was higher in the lower social classes.
In a Special Education class, designed for very
slow learners and those students who had been
in school for a minimum of seven or eight years,
this survey showed that over half of them were
regular smokers, the highest incidence of smok-
ing in all the classes in all three surveys. Be-
cause this class is an ungraded group, the statis-
tics for it were not included in Tables I and II.
The highest incidence of smoking in all regular
classes was found in the boys of the 12th grade,
1964, where 43% were regular smokers. This
group had the highest incidence of smoking in
all surveys reported including Portland, Winni-
peg, etc. It would seem that forbidden fruits
become sweeter when their existence is pointed
out to the teenagers.
This anti-smoking campaign as a public edu-
cation idea, is comparable to the use of the mo-
bile x-ray units which, in theory, were supposed
to find all cases of active tuberculosis so they
could be isolated for treatment and thus elimin-
ate the disease. The catch was that only those
people who could be educated ever appeared for
chest x-rays. Those with the highest incidence
of tuberculosis avoided the units and thus were
not discovered, so tuberculosis remains the same
problem today as it was ten years ago. In try-
ing to educate teen-agers regarding the hazards
of smoking, I found that the program did no
good and possibly some harm in the high school
group, and that it definitely increased the num-
ber of smokers in the junior high school level.
What, then, is the answer? First, this emotion-
al approach, the ‘scare technique,’ should be
abandoned. Second, the hazards of smoking
should be included in the regular health educa-
tion courses and should be presented to 4th
grade students, then repeated in similar classes
in 5th and 6th grades.
CONCLUSION
An evaluation of all educational programs is
necessary to determine if they are achieving
their purpose. I had hoped that, when presented
with facts and given the opportunity to read the
literature placed at their disposal, those stu-
dents who were smoking would stop, and that
their attitude toward smoking would change to
one of strong opposition. Neither of these things
happened. Still upon reflection, why should the
younger generation who, as yet, have minimal
functional loss from cigarette smoking, be ex-
pected to change their habits suddenly when
they are surrounded by their elders who con-
tinue to smoke even though they may have life
threatening diseases which are worsened by
cigarette smoking.
This means that an educational anti-smoking
campaign defeats its purpose and actually in-
creases the numbers who smoke.
BIBLIOGRAPHY
1. Beckerman, S. C., Report of an Educational Pro-
gram Regarding Cigarette Smoking among high
school students. J. Maine Med. Assoc. 54:60-63,
71, March 1963.
(Continued on Page 61)
46 —
Photo professionally posed
Mike expects a penicillin injection.
He’s about to be pleasantly surprised.
His physician is going to prescribe an oral penicillin
— Pen«Vee® K (potassium phenoxymethyl penicillin).
It’s usually so rapidly and completely absorbed that
therapeutic serum levels are produced in 15 to 30
minutes. Higher serum levels generally last longer
than with oral penicillin G.
Indications: Infections dueto pathogens susceptible to oral penicillin G.
Prophylaxis of rheumatic fever in patients with previous history of the
disease.
Precautions: Skin rash, symptoms resembling those of serum sickness,
or other manifestations of penicillin-allergy may occur. Measures for
treating anaphylaxis should be readily available: epinephrine, oxygen
and pressor drugs for relief of immediate allergic reactions; anti-
histamines and corticosteroids for delayed effects. Penicillin may delay
or prevent the appearance of primary syphilitic lesions. Patients with
gonorrhea who are suspected of concurrent syphilitic infections should
be tested serologically for at least 3 months. Where lesions of primary
syphilis are suspected, dark-field examination should precede use of
penicillin. As with other antibiotics overgrowth of nonsusceptible
organisms may occur: if so, discontinue and take appropriate measures.
Treat ^-hemolytic streptococcal infections with full therapeutic dosage
for at least 10 days to prevent development of rheumatic fever or glo-
merulonephritis.
Contraindications: Infections caused by nonsusceptible organisms;
history of penicillin sensitivity.
Composition: Tablets— 125 mg. (200,000 units) and 250 mg., (400,000
units); Liquid — 125 mg. (200,000 units) and 250 mg. (400,000 units)
per 5 cc. Wyeth Laboratories Philadelphia, Pa.
«l pEH.yEE k
(potassium phenoxymethyl penicillin)
C1INIC0PATH0106ICAL CONFERENCE - SIOUX VALLEY HOSPITAL
From the Intern and Resident Teaching Conferences of the Sioux Valley Hospital, Sioux Falls
JAMES A. RUD, M.D *
Pathologist - Editor
MICHAEL R. FERRELL, M.D.**
Internist - Discusser
This 68-year old Caucasian female was trans-
ferred to Sioux Valley Hospital for intermittent
chills and fever of three and one-half weeks
duration.
The patient had not been well following a bi-
lateral inguinal herniorrhaphy one month pre-
vious. She had abdominal pain, burning and
nausea since the operation and her temperature
had ranged from 101° to 103°F orally. She was
hospitalized elsewhere and received chloramph-
enicol, 1 gram every 8 hours and penicillin, 1.2
million units daily. Subsequent to this she de-
veloped diarrhea. Seven to ten days prior to
admission she developed lumbosacral tenderness
on percussion. Laboratory work revealed a leu-
kocyte count of 8000/m3, hemoglobin of 11.5
gm%, and erythrocyte sedimentation rate of 11
mm/hr.
Systemic review: Except for frequent head-
aches since childhood and dyspnea of several
months duration the systems review, past his-
tory, and family history were non-contributory.
She had been deaf for thirty years.
Physical examination: The patient was an ac-
utely ill, dehydrated, and toxic elderly woman
who was listless and had poor memory for re-
cent events. She had bilateral deafness and
quite severe lumbosacral pain produced by
moderate percussion. The remainder of the
physical examination was unremarkable.
Laboratory and x-rays: The admission hemo-
gram showed a hemoglobin of 13.5 gm%, RBC
4.57 million/mm3, hematocrit 40 vol%, MCH
29, MCV 88, MCHC 34, WBC 7800/mm3. The
differential count showed 76% segmented neu-
trophils, 1% bands, 1% eosinophils, 20% lymph-
ocytes and 2% monocytes. The VDRL was nega-
tive. The sed rate was 11 mm/hr, serum biliru-
bin 0.8 mg%, FBS 109 mg% and 139 mg%. Blood
urea nitrogen was 15 mg%. Urinalysis showed
a specific gravity of 1.015, pH 5.5, protein - neg-
ative, sugar-negative, hemoglobin -negative, and
0-1 WBC/hpf. Four days later the specific grav-
*Chief Resident in Pathology, Sioux Valley Hospital.
** Assistant Professor of Internal Medicine, School of
Medicine, University of South Dakota, and Intern-
ist, Sioux Valley Hospital.
ity was 1.016, pH 6.0, protein 1 + , sugar 2 + , ke-
tones - negative, hemoglobin - negative, and 2-4
WBCs/hpf with a few bacteria. Blood cultures
were reported as negative after three days incu-
bation. Agglutination tests for paratyphoid A
and B, typhoid O and H, proteus OX19, and tu-
laremia showed no titer. The brucella agglutina-
tion showed a titer of 1:40. Urine culture showed
no growth after 48 hours. Electrolytes showed
CO2 content 29 meq/L, Na 117 meq/L, K 2.6 meq
/L, and chloride 73 meq/L. The spinal fluid 8
days after admission yielded 1.9 ml. of slightly
turbid and xanthochromic fluid. The cell count
was 9 red blood cells/mm3 and 50 white blood
cells/mm3 with a differential of 15% polynu-
clears and 85% mononuclears. The CSF protein
was 235 mg%, (normal 15-45 mg%) and the LDH
was 160 units (normal 0-40 units). On the same
date ventricular fluid showed a total cell count
of 690/mm3 with 380/mm3 red blood cells and
310 white blood cells/mm3 with a differential of
16% polynuclears and 84% mononuclears. The
ventricular fluid protein was 60 mg% (normal
0-15 mg%). Routine culture on ventricular fluid
showed no growth after 48 hours.
A chest x-ray showed a probable tuberculoma
in the right lung base. Antero-posterior and
lumbo-sacral films showed mild degenerative
changes in the lower lumbar region. The gall-
bladder was not visualized and the upper GI
series was normal except for a small diaphrag-
matic hernia. A barium enema was normal and
subsequent visualization of the gallbladder was
normal.
Hospital course: A surgical consultant report-
ed the hernia repair was satisfactory. A second
surgical consultant thought the chest lesion was
probably granulomatous but if of recent origin
the possibility of neoplastic disease could not
be ruled out. He believed the fever was not due
to pulmonary pathology but was probably re-
lated to postoperative urinary tract infection.
She continued a progressive downhill febrile
course and became comatose on the sixth hos-
pital day. A psychiatrist found her stuporous
with Cheyne-Stokes respirations. His impres-
sion was that of intracranial pathology rather
48 —
APRIL 1967
than psychiatric disease and had a neurologist
see her. The patient’s blood pressure had in-
creased to 210/100 prior to his examination but
when he saw her it was in the range of 150-180
systolic. The pulse ranged from 100-120 and was
rapid and somewhat thready. She continued to
have Cheyne-Stokes respirations and the pupils
were dilated and fixed. There was no verbal re-
sponse. She responded to painful stimuli. There
were no focal or localizing signs. There was no
deviation of the eyes, no papilledema, and no
retinal hemorrhages. The left lower extremity
was initially rigid and a few moments later be-
came flaccid. The deep tendon reflexes were 1 +
bilaterally and the Babinski reflexes were
equivocal. There was an attempt at withdrawal
of the lower extremities to painful stimulation
which also evoked an extensor response in the
upper extremities. The neurological impression
was that the patient probably had some type of
cerebral neoplasm, brain abscess, or cerebral
vascular disease. A cerebral decompression pro-
cedure was carried out. She expired on the tenth
hospital day without regaining consciousness.
CLINICAL DISCUSSION
Dr. M. R. Ferrell: The following diagram (Fig.
1) is a graphic illustration of the sequence of
events and my thinking in arriving at a diagnos-
is in this case.
Fig. 1
A. '
Abdominal Pain
and 6 months
Burning
Operation
GX
CNS Expired
Fever
B.
Tumor
Cancer of Stomach
Cancer of Pancreas
Hypernephroma
Ruled
Out
Collagen Systemic Lupus Erythematosus
Disease Polyarteritis
Ruled
Out
Infection
Bacterial
Fungal Tbc.
Viral-
Spinal Fluid
- 15% polys
- 85% mono
We have a patient in whom complaints of ab-
dominal pain and burning have been present
for about 6 months. She had a bilateral inguin-
al herniorrhaphy and almost immediately she
developed further gastrointestinal and central
nervous system complaints. She then expired.
This lady was living in symbiosis with some
disease process during this entire period. The
operation upset this symbiosis and the relation-
ship became less favorable to her resulting in
her death. I think something chronic is going on
in this patient that was precipitated to an acute
episode by the operative procedure.
I think of tumor, infection and collagen dis-
ease in general terms as diagrammed. When you
read through the protocol, it could be any one
of these. What I was looking for (and I think I
found them) were some sign posts to direct me
to the diagnosis.
In the tumor group I considered three possi-
bilities: carcinoma of the stomach, carcinoma
of the pancreas, and hypernephroma. Although
from the clinical picture any of these could be
present, I ruled them out on the basis of find-
ings such as negative gastro-intestinal x-rays
on two occasions, an indication of some normal
liver function, an indication of normal kidney
function with a normal BUN, no hematuria and
no mass in the abdomen.
Collagen diseases, such as lupus erythema-
tosus and polyarteritis, could produce this clin-
ical picture very easily. Again, with lupus you
would certainly expect some renal changes such
as BUN elevation and proteinuria. In polyarter-
itis I would expect to find some other physical
signs along with definite renal changes. In poly-
arteritis, there is renal involvement in a large
percentage of cases; the parameters that we have
here do not show kidney damage. Since she is
obviously severely dehydrated, the urine specif-
ic gravities of 1.016 and 1.015 may be a reflec-
tion of the fact that she could not concentrate
her urine which is a very good indication of
severe renal disease. However, she may have
been getting very good intravenous fluid ther-
apy and was just pushing fluids right on
through. She obviously was losing a lot of fluids
in the gastro-intestinal tract because the serum
sodium, potassium, and chloride were decreased.
There was no indication from the protocol that
she was losing them elsewhere.
When I consider infections, I include diseases
caused by bacterial, fungal, and viral organ-
isms. Among the diseases caused by bacteria, I
ruled out everything with the possible excep-
tion of tuberculosis and spirochetal disease on
the basis of the differential white blood count in
the cerebrospinal fluid which was 15% polymor-
phonuclear cells and 85% mononuclear cells.
(Fig. 1) The predominance of mononuclear cells
in the cerebrospinal fluid is suggestive of tu-
berculosis, spirochetal disease, viral disease, and
possibly some fungal disease but not of acute
bacterial disease. The cerebrospinal fluid pro-
tein may be elevated by any one of these dis-
eases as can the LDH (Lactic dehydrogenase).
The differential in the protein between the ven-
49
SOUTH DAKOTA
tricular and lumbar cerebrospinal fluid is mere-
ly the concentration differential between the
fluid from the two sites. Normally the protein
concentration of ventricular fluid is about 15
mgm% and lumbar is about 45 mgm%.
As far as fungal disease is concerned, the
spinal fluid in cryptococcosis is usually of gel-
atinous consistency. With blastomycosis there is
almost always a skin lesion. Histoplasmosis and
coccidiomycosis cannot ordinarily be differen-
tiated from tuberculosis in the spinal fluid be-
cause they are usually very similar.
Viral disease, of course, is a possibility. How-
ever, I don’t consider it likely with this clinical
course.
Next to meningococcus, tuberculosis is one of
the more common meningitides in adults. Per-
haps we should look at the chest x-ray next.
Dr. Bryson R. McHardy*: The lesion men-
tioned in the protocol is in the right lower lung
field just above the costophrenic angle (Fig.
II). It has a nicely calcified center which would
make it more probable that this is a granuloma.
With the calcification you cannot exclude a
hamartoma but the likelihood of neoplasm
would be very small. The chest is otherwise nor-
mal.
Dr. Ferrell: You notice there was tenderness
on palpation and percussion of the back. Is there
x-ray evidence of what may be causing that?
Fig. II - Note lesion at right costophrenic angle.
*Radiologist, Sioux Valley Hospital
Dr. McHardy: She had mild scoliosis and
spondylolisthesis of L4 and 5 which might ac-
count for the back pain. The calcification within
the wall of the abdominal aorta is about usual
for a 68-year old. She also had a hiatal hernia.
Dr. Ferrell: This is also a typical picture for
brucellosis, especially with back pain. This is
very characteristic along with the type of fever
which she had, but again I would hope to see
a higher titer.
Salmonellosis should also be considered since
Salmonella bacteremia can cause brain abscess
and meningitis. We do not have all of the titers
here but do have Paratyphoid A and B and Ty-
phoid O and H, all of which are negative. The
most common organism that causes this picture
is Salmonella enteritidis, a group D organism.
Another very exotic cause is Listeria mono-
cytogenes which is apparently more common in
females because it involves the genital organs.
This can also produce a picture very similar to
this lady.
You have to decide on a diagnosis in C.P.C.
discussions. With the clinical picture and course
together with the sign posts I discussed earlier,
I decided that she had tuberculous meningitis.
Tuberculous meningitis can sneak up on you.
It can involve the brain stem. The terminal pic-
ture of tuberculous meningitis looks like this
with the Cheyne-Stokes respirations, the flac-
cidity and the lack of pupillary response. Many
cases of tuberculous meningitis may show no
other clinical manifestations of tuberculosis.
This lady does since she probably has a tuber-
culoma. That hard core center with soft hazi-
ness surrounding it is significant to me. I wish
there was a PPD skin test but none is recorded.
I have had the impression that there is an
actual dissemination of the tubercule bacillus
from the foci of infection at the time of trauma
or stress. Apparently this is not true according
to what I have been able to gather. There are
tuberculomas that are actually pockets of tu-
berculosis in the meninges and brain that break
down. She may have been festering along with
this for many years. When she was stressed
these then broke down and involved the menin-
ges and the brain rather than spreading from
the chest at this particular time.
Dr. Roberl Nelson*: Assuming the mycobac-
terium is the human type and not resistant to
drug therapy, how would you treat central ner-
vous system tuberculosis? What drug or com-
bination of drugs would be most effective?
^Surgeon, Sioux Valley Hospital.
— 50 —
APRIL 1967
Dr. Ferrell: The three primary anti-tuber-
cular drugs are para-aminosalicylic acid (PAS),
isoniazid (INH), and streptomycin. These should
be given in combination in high doses. In cases
such as the one we have just discussed, steroid
therapy is probably also indicated.
Dr. Nelson: Do all of these drugs cross into
the spinal fluid?
Dr. Ferrell: No, not as well as you might think.
Isoniazid has the greatest facility for crossing
into the spinal fluid rapidly and does very well;
followed by para-aminosalicylic acid and then
streptomycin. The addition of steroids in severe
cases can be life-saving.
In this case I would have begun treatment on
the basis of the history, clinical findings and
the x-ray lesion in the lungs without a positive
PPD skin test. Of couse, a positive test would
have made me more confident in making such
a diagnosis and in instituting therapy. I recall
a recent case of miliary tuberculosis where in
retrospect the diagnosis and treatment were de-
layed too long. I discussed this case with sever-
al men in Milwaukee. One of them asked me a
very pertinent question with which they all
agreed. He wondered about monocytosis in the
peripheral blood smears. Monocytosis is appar-
ently a very common accompaniment of miliary
and central nervous system tuberculosis. In this
lady’s case, the peripheral blood was normal;
however, there was an increased number of
mononuclear cells of the cerebrospinal fluid.
Dr. Karl H. Wegner*: Monocytosis is typical-
ly associated with an active and progressive clin-
ical tuberculosis. A decreasing monocytosis is
associated with clinical improvement of the tu-
berculosis.
Dr. John F. Barlow**: This is the so-called
Medlar ratio which has been used as a prognos-
tic indication. Increasing monocytes with de-
creasing lymphocytes indicate a poor prognosis
while vice-versa is a good prognostic sign.
Dr. Ferrell: I had the opportunity to treat
several cases of tuberculous meningitis while
stationed in the Army at Fitzsimmons General
Hospital. We had cases almost as sick as this
lady and used triple drug therapy along with
steroids and they recovered satisfactorily. How-
ever, this is all retrospective thinking.
Dr. Bill G. Church***: Was there much in the
way of residual central nervous system damage
in those patients?
Dr. Ferrell: No, amazingly not.
*Pathologist, Sioux Valley Hospital
**Pathologist, Sioux Valley Hospital
***Neurosurgeon, Sioux Valley Hospital
Dr. Barlow: I would like to comment on the
Salmonella agglutination titers. I agree that the
use of Typhoid O and H and somatic O of para-
typhoid A and B titers is outmoded. This is be-
cause O antigens are much better to use than
H antigens and the typhoid O, paratyphoid A
and B do not cover all of the major O groups of
Salmonella. Infections due to Salmonella of
other O groups than typhoid, which is a group
D, are actually much more common than dis-
ease due to Salmonella typhosa, the organism of
typhoid fever. We now routinely do titers
against the major Salmonella O groups — A,
B, C, D, E.
Dr. Ferrell's diagnosis:
Miliary tuberculosis with tuberculous meningitis.
PATHOLOGICAL DISCUSSION
Dr. James A. Rud: Autopsy revealed a calci-
fied 1.5 cm. nodule in the right lower lobe as
well as multiple 0.2-0. 3 cm. nodules throughout
both lungs, the liver, and the spleen. Microscop-
ically these were tubercles with a typical
granulomatous appearance — the periphery con-
Fig. Ill - Granulomas in spleen
Fig. IV - High power of granuloma in lung
51 —
SOUTH DAKOTA
taming numerous lymphocytes, fibroblasts, and
plasma cells. There were scattered multinu-
cleated giant cells. In larger tubercles central
caseation necrosis was present (Fig. Ill, IV).
The meninges were diffusely opaque and ap-
peared thickened. These changes were most
prominent over the lateral and inferior surfaces
of the brain. Extensive laminar hemorrhages
involved the cortex and the underlying superfi-
cial white matter. The basal ganglia and brain
stem showed extensive hemorrhagic necrosis.
These changes were thought to be due to severe
anoxic encephalopathy (Fig. V).
Fig. V - Brain with areas of hemorrhagic necrosis
in cortex and basal ganglia
Microscopically the surface of the brain was
covered by a cellular fibrinous exudate. Within
the meninges were large numbers of lympho-
cytes, plasma cells and histiocytes (Fig. VI).
Fig. VI - Close-up of meningeal exudate
Ziehl-Nielsen stains revealed innumerable acid
fast organisms of characteristic appearance
scattered throughout the exudate covering the
brain and similar organisms were in the tuber-
cles of the lungs, liver and spleen.
We are dealing with a disease which occurs
most commonly in children although no age is
exempt. Those persons between the ages of six
months to five years of age are especially vul-
nerable.
Tuberculous meningitis is usually due to the
human type of Mycobacierium tuberculosis. The
bovine type of organism may cause a signifi-
cant number of cases in children in those parts
of the world where raw milk products are con-
sumed. Pasteurization of milk and milk prod-
ucts in this country has caused a marked de-
crease in incidence of the disease.
The pathogenesis of the disease has not been
fully explained. Various theories have been pro-
posed. Among these: (1) Direct hematogenous
spread to the meninges would appear to be the
obvious cause when it is a part of miliary tu-
berculosis. However, Rich and McCordock (^2)
injected the organisms into the carotid arteries
of animals and showed that they do not develop
primary tuberculous meningitis but do develop
generalized miliary tuberculous nodules
throughout the body. They also found that dir-
ect injection into the subarachnoid space result-
ed in tuberculous meningitis. They thought that
in the majority of cases, meningitis was second-
ary to a small focus in the cortex or meninges
and found support for this theory in 90 per cent
of their cases.
Hektoen3 proposed that the infection reached
the meninges by passing through the walls of
the small arteries or veins, the walls of which
might be entirely replaced by tuberculous gran-
ulation tissue.
Hematogenous spread to the choroid plexus
with secondary spread to the walls of the ven-
tricles and subarachnoid space was suggested
by Kment4. In his series, he found tuberculo-
mas in the choroid plexus in 60 per cent of the
cases. Beres and Metzler5 found lesions in this
location in 39 per cent of their cases.
Greenfield6 divides tuberculosis of the men-
inges into two separate entities. The term men-
ingeal tuberculosis has been applied to those
cases in which tuberculomas may be found in
the leptomeninges. They may give rise to gen-
eralized meningitis but this is not a constant
(Continued on Page 61)
— 52
APRIL 1967
(Continued from Page 62)
finding. Generalized tuberculous meningitis is
the term applied to cases arising from general-
ized miliary tuberculosis and would be most
apropos in the present case. It is associated with
miliary tuberculosis in 70-80 per cent of ail cas-
es and the primary focus is within the lung in
about 70 per cent of all cases.
PATHOLOGICAL DIAGNOSIS
1. Pulmonary tuberculosis with miliary tu-
berculosis and tuberculous meningitis.
2. Anoxic encephalopathy, secondary to
above.
BIBLIOGRAPHY
1. Rich, A. R., and McCordock, H. A.: Bull. J. Hop-
kins Hosp., 4: 273, 1929.
2. Ibid. 52: 5, 1933.
3. Hektoen, L., J. Exper. Med., 1: 112, 1896.
4. Kment, H., Tuberk. Biblioih., 14: 1, 1924.
5 Beres, D., and Metzler, T., Amer. J. Path., 14: 59,
1938.
6 Greenfield’s Neuropathology, W. Blackwood et al
(editors), The Williams and Wilkins Company, Bal-
timore, 1963.
ANTI-SMOKING —
(Continued from Page 46)
2. Cartwright, A., Martin, F. M. and Thomson, J. G..
Efficacy of an Anti-smoking Campaign. Lancet,
1:327-9, (Feb. 6) 1960.
3. Horn, D., Courts, F. A., Taylor, R. M. and Solomon,
E. S.: Cigarette Smoking Among High School Stu-
dents. Am. J. Pub. Health, 49:1497-1511, 1959.
4 Matarazzo, J. D. and Saslow, G.: Psychological
and Related Characteristics of Smokers and Non-
smokers. Psychol. Bull., 57:493-513, 1960.
5. Maine Dept, of Health & Welfare. The impact of
an educational program on Teen-age smoking
habits. J. Maine Med. Assoc. 54:108-11, May, 1963.
6. Morrison, J. G. and Medovy, H.: Smoking Habits
of Winnipeg School Children. Canad. Med. Assoc.
J., 84:1006, 1961.
7 Salber, E. J., MacMahon, B., and Welsh, B.: Smok-
ing Habits of High School Students related to In-
telligence and Achievement. Pediatrics 29:/ 80-8/,
1962.
8. Salber, E. J., MacMahon, B., and Harrison, S.: In-
fluence of Sibling on Student Smoking patterns.
Pediatrics 31:569-72, 1963.
9. How to Stop Student Smoking. School Manage-
ment pp. 70-74, March 1964.
■COCA-COLA" AND "COKE" ARE REGISTERED TRADE-MARKS WHICH IDENTITY ONLY THE PRODUCT OF THE COCA-COLA COMPANY.
For the taste
never
— 61 —
Preventable and Avoidable Cancers
and
Cancers Arising From Personal Indifference
Wendell G. Scott, M.D.
Professor of Clinical Radiology
Washington University School of Medicine
Saint Louis, Missouri
The field of cancer prevention offers greater
possibilities for the control of cancer and the
saving of lives than any other measure we have
at our command today. Surely it is better to
prevent the occurrence of a cancer than it is
to try to cure it once it has occurred.
It may be surprising to some of you that can-
cer can be looked upon as pre-eminently a so-
cial disease and as a public health problem. It
is a social disease because, as we shall see, so-
cial conditions contribute heavily to its cause
and social measures are required for its control.
Economic circumstances also have a direct bear-
ing on this disease. For example, a recent study1
of the records of the California tumor registry
indicates:
That cancer of the cervix is twice as frequent
in the lowest income groups as in the highest;
That among men, lung and stomach cancer
strike the lowest income group twice as fre-
quently as it does those with the highest in-
comes;
That only 1/3 of the cancer patients in county
hospitals received early diagnoses, while V2 of
those in private hospitals received the benefits
of early diagnosis;
That as a result of early diagnosis and better
treatment, 62 per cent of private hospital pa-
tients with cancer of the cervix survived five
years or more but only 39 per cent of the coun-
ty hospital patients survived five years; and
That 2/3 of the women in the highest social
class had at least one Pap test, but less than
1/3 of the women in the lowest income group
had received this benefit.
The understanding of these factors together
with the knowledge that is being accumulated
from the geographical pathology of cancer are
Reprinted with permission from the Journal of the
Medical Association of the State of Alabama, Volume
36, Number 3, September, 1966.
the major developments in the control of can-
cer today. These are the factors I am going to
discuss.
Until recently, the primary objective of can-
cer prevention has been limited to the early di-
agnosis of malignant disease, and preferably at
the pre-cancerous stage. Actually, the therapy of
pre-cancerous lesions forms the cornerstone of
cancer prevention, and with current methods
of treatment, results in a high rate of cure. The
knowledge about extrinsic carcinogens in man’s
environment has been developing so rapidly that
it is now possible to eliminate or to control many
of the factors that not only affect particular oc-
cupational groups, but also the general popula-
tion.
The potential scope of cancer prevention is
limited by the number of human cancers in
which extrinsic factors are responsible. These
include all environmental carcinogens, or can-
cer forming agents whether already identified
or not, as well as “modifying factors” of intrins-
ic origin such as hormonal imbalances, dietary
deficiencies, and metabolic defects. The types of
cancer that are influenced by extrinsic factors,
directly or indirectly, include many tumors of
the respiratory system; the gastrointestinal and
urinary tracts; the skin and mouth; the hor-
mone dependent organs such as the breast, thy-
roid and uterus, and the blood and lymphatic
systems. Collectively these account for about
three-fourths of all human cancers.2 Thus it
would appear that the majority of human can-
cers are potentially preventable.
What do we mean by cancer prevention? It is
defined by the World Health Organization Ex-
pert Committee on the Prevention of Cancer as
“the elimination of, or protection against, fac-
tors known or believed to be involved in carcin-
ogenesis and the treatment of pre-cancerous con-
ditions.”
— 6? —
APRIL 1967
Experimental evidence has established that
there is a long latent period of carcinogenesis,
as for example in carcinoma of the cervix, in
which it has been found to be about eight years.
During the latent period the events leading to
the eventual development of the tumor may be
stopped in a variety of ways:
1. By the prevention of the carcinogenic pro-
cess from arising in the first place.
2. By prevention of the tumor from eventual-
ly developing.
3. By forestalling the development of the tu-
mor by appropriate detection methods.
The signs and symptoms of pre-cancerous le-
sions are recognizable in many sites including
the skin, mouth, pharynx, esophagus, stomach,
colon, rectum, female reproductive organs and
breasts. In some cases they are first recognized
by the alert patient. We should encourage peo-
ple to be aware of them, and to consult a doctor
on what may appear to them to be trivial mat-
ters, such as senile keratoses, leukoplakia, pol-
yps of the gastrointestinal tract, unusual bleed-
ing or discharge from a body orifice, a lump or
thickening in the breast or in tissues elsewhere,
a persistent change in bowel or bladder habits
of two weeks duration, persistent hoarseness or
cough, persistent indigestion or difficulty in
swallowing, and a change in a wart or mole.
These symptoms may NOT mean cancer, but
any one of them should ALWAYS mean a visit
to a physician.
The study of the incidence of cancer in dif-
ferent countries and even in different areas of
the same country offers one of the most promis-
ing ways of obtaining new clues to the etiology
of this disease. Geographic cancer pathology
has become of age but much still remains to be
learned about the incidence of the various types
of cancer in Africa, in Asia, and Central and
South America and elsewhere. Cancer incidence
is not static, however, and rapid changes in the
social and economic organization are taking
place in almost every country. It is, therefore,
important that information be obtained now,
while big differences in the incidences of vari-
ous cancers still exist in the undeveloped coun-
tries. Once lost, this opportunity may never re-
turn. This is why the American Cancer Society
and the National Cancer Institute are encour-
aging and supporting epidemiology studies in
many countries throughout the world and al-
ways with the hope that new carcinogenic fac-
tors in these environments may be found.
Until relatively recently, cancer prevention,
considered in terms of elimination or protection
against known carcinogens, has been restricted
to a group of chemical substances known to
give rise to cancer among limited occupational
groups. We have now come to realize that these
same compounds can gain entry into the general
environment, the atmosphere, the water, and
the soil, as potential carcinogenic pollutants and
with increasing contamination may become of
importance in the occurrence of cancer in the
population at large.
The spectrum of such carcinogens is of neces-
sity broad and encompasses every type of chem-
ical agent, synthetic and natural, certain physi-
cal agents, viruses, and radiations of various
types. In fact, man is in no position to ignore
seemingly unimportant possibilities of other
types simply because we don’t know about them
today.
The identification of those environmental fac-
tors that have a causal relationship in the devel-
opment of cancer can provide us with a short
cut in the control of many cancers. It is those
cancers which are directly related to factors in
our environment that I refer to as “Preventable
and Avoidable Cancers and Cancers Arising
from Personal Indifference.”
The classical example and the first identifica-
tion of an environmental chemical causative
agent of cancer in man was cancer of the scro-
tum.3 It was a common occurrence among chim-
ney sweeps, nearly 100 times more frequent than
in the general male population. It was caused
by their years of contact with soot. When this
was realized, protective clothing and cleanli-
ness were instituted and this avoidable cancer
has practically disappeared. Sir Percival Pott
made this acute observation in England in
1775. 3
The most common of all cancers, cancer of the
skin, is an avoidable cancer. It occurs almost ex-
clusively on those parts of the body exposed
to sunlight; is more common in regions of the
earth receiving more ultraviolet radiation; is
much more frequent in the light-skinned people
than in dark-skinned, and appears most often
in people engaged in outdoor occupations. It is
induced by prolonged over-exposure to sunlight,
to ultraviolet lamps, to arsenic, to certain oils
and chemicals, all of which agents it is possible
to avoid, and thus to prevent this form of can-
cer.
Because it occurs on the skin, it is easily seen,
recognized early, promptly treated and cured.
The cure rate for skin cancer is 93 per cent in
the United States, but because of the high inci-
— 63 —
SOUTH DAKOTA
dence the seven per cent failures account for
over 4,000 unnecessary deaths every year.4
Another cancer which is avoidable is a partic-
ular type that occurred in the bladder of up-
wards of 70 per cent of the chemical workers
that were heavily exposed to aniline dye inter-
mediates, and especially to betanaphthylamine.5
When this chemical was identified as the cul-
prit and exposure to it was stopped, this particu-
lar cancer disappeared and the overall incidence
of bladder cancer in this group of men returned
to normal.
Recent studies by Wynder5 and associates re-
port that cancer of the bladder is predominant-
ly a male disease, that it is increasing in some
countries, including the United States, and that
cigarette smoking increases the risk of bladder
cancer by about two-fold. They also point out
that shoe repairers appear to have a higher in-
cidence of bladder cancer and that they should
be advised to handle dyes and polishes with
more care, and to wash their hands frequently
with soap and water as a means of reducing
their higher risk to this disease.
The age-adjusted death rate for cancer of the
bladder varies according to the country, from
eight per 100,000 in South Africa to only two
per 100,000 in Japan, and about four per 100,000
in the United States. In Egypt it increases to
about 11 per 100,000, possibly due to the high
incidence of schistosomiasis. It is reasonable to
assume that the excess cases of bladder cases
among male subjects are related to exogenous
causes, and that preventive steps can contribute
significantly to a reduction in bladder cancer
frequency.
Among industrial workers it has long been
known that about 50 per cent of the miners in
the pitchblende mines in Joachimsthal,6 and
about 75 per cent of the miners in Schneeberg,7
both in Czechoslovakia, dying from natural
causes, died from cancer of the lung brought
about by their prolonged exposure to radioac-
tive ores. At about the same time it was also
recognized that the estimated life-time inci-
dence of lung cancer in chromate ore refining
workers was approximately 35 per cent.8 We
are now learning that the inhalation of asbestos
fibers9 can also be a responsible agent in the
causation of cancer of the lung, as well as of
malignant mesotheliomas of the pleura and per-
itoneum and that even mild inhalation of asbes-
tos fibers10 is capable of giving rise to these
malignant tumors. Likewise, the inhalation of
beryllium salts and oxides2 by workmen hand-
ling these products has proven to have a high
carcinogenic potential in the production of lung
cancer. It is a curious but well established fact
that men refining nickel ores developed cancers
of the ethmoid sinuses in a surprisingly high in-
cidence.2 Another substance, cobalt,1 when ac-
cidentally injected or thrust beneath the skin al-
most invariably caused a cancer to develop at
this site. Fortunately, exposure to all these car-
cinogenic substances can and are being elimin-
ated by modern protective industrial practices
and these cancers avoided.
The most important environmental causal
agent in the production of internal cancer to-
day is, of course, the prolonged inhalation of
cigarette smoke. The evidence that inhalation of
cigarette smoke is the major cause of lung can-
cer and a major health hazard is overwhelming
from the statistical, the pathological, the experi-
mental and the clinical evidence. Every medical
and health organization in this country and
abroad that has studied this subject has con-
cluded that cigarette smoking is a serious health
hazard. There have been no exceptions. Unfor-
tunately, cancer of the lung is one of the most
fatal of all cancers, with only five patients out
of every 100 surviving five years.
It is tragic that the medical profession and the
public have been so long in recognizing that
cancer of the lung is largely an avoidable can-
cer. This cancer for the most part is due to the
personal indifference of the individual who pre-
fers not to accept the ever increasing evidence
of the causal relationship between the inhala-
tion of cigarette smoke and lung cancer, I choose
to call this process “Cancer Arising from Per-
sonal Indifference.”
An interesting report by Moore1 1 appeared in
the Journal of the American Medical Associa-
tion for January 25, 1965, in which he divided
a group of 102 smokers, all of whom had been
“cured” of mouth or throat cancer, into two
groups: 65 who continued smoking, and 37 who
stopped. Within approximately six years about
1/3 of those who continued smoking acquired a
second “tobacco area” cancer, while only two
of the quitters developed second cancers in this
same period. It was also significant that most
persons in their locality who developed mouth
and throat cancer smoked cigarettes, and those
who continued to smoke and developed second
cancers were nearly all cigarette smokers. In
the past the impression has been that only cigar
and pipe smokers, or tobacco chewers, acquired
mouth cancers, but from this study it would
appear that tobacco in any form can cause can-
cer of the mouth and throat.
64
APRIL 1967
I wonder if any of us as recently as five years
ago would have predicted that cancer of the
cervix in women would be considered an avoid-
able cancer today. Twenty years ago this cancer
was the Number One killer of women. During
this interval the death rate from cervical can-
cer has dropped about 50 per cent. In recent
years the “Pap” test has given a tremendous im-
petus to the control of cervical cancer. A 1964
survey by the Gallup Organization indicated
that 48 per cent of adult women claimed to have
had a “Pap” test, whereas in 1961 this figure
was only 30 per cent. From this data we can as-
sume that 27 V2 million women have had at least
one test, but this is not enough. Every woman
should have this protection.
The efficiency of the “Pap” test in the control
of cervical cancer has been demonstrated in
Louisville, Kentucky,12 where Pap smears have
been done on a large group of women for the
past ten years. For the last seven years not one
single case of invasive cancer of the cervix has
appeared among these women, proving that
yearly cytological screening provides essential-
ly 100 per cent protection, and one can say that
a death from cancer of the cervix is a prevent-
able death. It need only occur from personal in-
difference.
It may also be considered an avoidable cancer
as well, for investigators are now finding a caus-
al relationship to certain environmental factors.
Cervical cancer has a much higher incidence in
countries where adequate personal hygiene is
difficult to obtain, and has the lowest incidence
in countries in which the plumbing facilities are
better. In Singapore it was demonstrated to me
that those women who have access to a private
bathroom have a lower incidence of cervical
cancer than those who do not. It is extremely
rare in nuns, and has the highest incidence
among prostitutes. It occurs more frequently in
married than in unmarried women, and even
more so in women who marry several times. It
is more frequent in those who marry young and
who initiate sexual relations at an early age.
It usually appears about 20 years after sexual
intercourse begins, which corresponds in laten-
cy period with that of other more accurately
measured forms of cancer.
A somewhat related and another avoidable
cancer is cancer of the penis. I say related be-
cause wherever the incidence of cancer of the
cervix is low, so is the incidence of penile can-
cer, and where one is very common, so is the
other. Penile cancer is probably the oldest of
avoidable cancers. It has been almost non-exist-
ent among the Jews in whom circumcision is
performed at the end of the first week after
birth as part of a religious rite. In Moslems cir-
cumcision is carried out before puberty, and
they also have a low incidence of this cancer.
In a series of 120 cases of this cancer at New
York Memorial Hospital for Cancer and Allied
Diseases, Dean13 reported that none of the pa-
tients had been circumcised in infancy. It has
also been established that circumcision after
the age of puberty is ineffective. In a country
as health conscious as the United States, this
cancer could be eradicated by mandatory cir-
cumcision and personal cleanliness. Where these
practices are neglected the incidence is consid-
erably higher as in Ceylon, South Africa, and
Latin America. In India it may account for as
much as ten per cent of all cancers in males and
up to 20 per cent in China. Mexico, in fact, may
have the world’s highest known incidence of
this disease. In the United States it amounts to
from one to three per cent of all cancer.14
The changing social customs that can lead to
cancer are complex and far reaching. Some cus-
toms, such as betel and nass chewing, are wide-
spread and apparently satisfy important human
desires. For instance, cancer of the oral cavity
and pharynx is by far the most common neo-
plasm in India and the Philippine Islands. The
Cancer Institute of Madras in India reports that
48 per cent of all malignant neoplasms were or-
al or pharyngeal in origin, with more than 20
per cent of them arising from the buccal mu-
cosa. In contrast, buccal cancers in the United
States account for only 4.6 per cent of cancers
in males and 1.7 per cent in females.
In India, the Philippines, Ceylon, Burma, Pak-
istan and Guam the extremely high incidence
of intraoral cancer occurs most frequently in
the low income groups and is related to the
national habit of chewing a mixture of tobacco
and slaked lime with betel nut. This “quid” is
placed in the mouth between the cheek and the
gum and kept there most of the day. It stains
their teeth and keeps their mouths filthy.
I have seen these “self-induced” cancers in the
Far East. It is pitiful to see these people when
you know that these cancers are not necessary
and that they are avoidable.
Unfortunately a similar habit exists in the
southeastern United States. It is “snuff-dipping,”
and is a fairly common habit, especially among
older women in low income groups. It is strong-
ly suspected that this habit is associated with
the increased incidence of intraoral cancer that
occurs in this area.
— 65 —
SOUTH DAKOTA
Snuff is no longer sniffed in the nose as was
fashionable in the 18th century. Today a pinch
of this flavored, powdered tobacco is placed in
the gingival buccal gutter. The users suck on
the quid most of the time they are awake. This
seems to be a particularly habit-forming use of
tobacco, and the prolonged use of it to a limited
area of mucosa produces severe chronic local
irritation that is an ideal environment for any
carcinogen in tobacco to exert its effect by dir-
ect contact.1 5
Snuff dippers’ intraoral cancers are not just
a casual or freak occurrence. The United States
Department of Agriculture reports that 34 mil-
lion pounds of snuff was sold in 1961 and much
of it in the southern states and in the Pacific
northwest.
Brown and associates16 in Atlanta, Georgia,
recently published their experience on 394 cases
of snuff dippers’ cancer. They found that 78
per cent of the cancers that occurred in the
buccal gutter were in women and 75 per cent
of them were confirmed snuff users and kept
the quid at this location.
A report from Nashville, Tennessee by Rosen-
feld and Calloway17 found that of the women
in a group of 525 intraoral cancers, 90 per cent
of them had carcinoma of the gingiva-buccal
area and were habitual users of snuff.
This is in contrast to reports from Buffalo,18
the Mayo Clinic,19 and from New York City,20
in which cancers of the oral cavity and pharynx
occur about five times more frequently in men
than in women.
In the Central Asian Republics of the U.S.S.R.
a habit known as “Nass-chewing” is practiced.
Nass is the meat from the nut of the nass tree.
It is mixed with tobacco, lime, ash, and butter,
and the “quid” is placed under the tongue and
between the lower lip and the gums. This prac-
tice also causes cancer to develop at the site of
application similar to those we have just de-
scribed.
In a narrow zone across Central Africa occurs
an unusual type of cancer — Burkitt’s sarcoma.
It was first thought to be limited to African
children. More thorough studies revealed that
it can appear in children of all races — European,
Asian, Indian, as well as in adults, but this high
incidence occurs only in those who live in areas
within this belt which have an elevation of less
than 5,000 feet; an annual rainfall of more
than 200 inches, and a temperature that does not
fall below 60 degrees Fahrenheit. These condi-
tions suggested that this type of cancer could
be due to a virus that was possibly transmitted
by a vector such as a mosquito.
These possibilities have now been almost con-
firmed by Dr. Michael Epstein of the Middlesex
Hospital Medical School in London, who has
been able to grow the cells of Burkitt’s sarcoma
in tissue culture and to show that these cells
elaborate a virus-like particle believed to be
the causative agent.
It should be pointed out that recently O’Con-
or21 has shown that a similar tumor occurs in
children in this country, and Dorfman22 has
demonstrated the same condition in children in
Missouri. They both believe that lymphosar-
coma in children in the United States, while
being a rare disease, is similar to Burkitt’s tu-
mor in Africa in age distribution, clinical mani-
festation, cause and histological appearance. The
unusually high incidence in a particular geo-
graphic area in Africa, its predilection for the
bones of the jaw and face and the rarity of leuk-
emic transformation, may reflect an attendant
host susceptibility in children in that area in
addition to the environmental factors.
There is a similar group of cancers which ap-
pear to be related to causal factors in our en-
vironment which we have not yet identified.
The first of these is cancer of the stomach,
which has been showing a remarkable decline
for the past 30 years in the United States for
no known reason. At the same time cancer of
the stomach has been continuing to increase in
Yugoslavia, Mexico, in India, and particularly
in Japan, where it is the Number One cancer.
It also continues to be a major cancer in the So-
viet Union and the Countries behind the Iron
Curtain, as well as in Iceland. Why? We don’t
know. It might be related in some way to the
low protein diet of these people, but we are
not certain. The Japanese who live in the United
States do not have the same high incidence. The
cause appears to lie in the difference in the en-
vironmental food habits of these different peo-
ples.
We would like to know why American wo-
men have about seven times as much cancer of
the breast as Japanese women. We think that
there is some connection in the length of time
they spend in nursing their children, but we
need much more research into glandular and
related functions to make sure. We should also
like to know why cancer of the breast is more
frequent in unmarried than in married women.
Cancer of the colon and rectum in the United
States is the Number One internal cancer
among men and women; 46,000 deaths will oc
— 66 —
APRIL 1967
cur from it this year, and there will be 76,000
new cases. It is the only cancer in which the in-
cidence is the same in both sexes. Yet in the
same countries that have a high incidence of
cancer of the stomach there is low incidence of
cancer of the colon. It is infrequent in Mexico,
Latin America, India, and in Japan.
Epidemiological studies just completed by
Haenszel23 of the National Cancer Institute
show a definite increase in cancer of the colon
in people in urban communities as compared
with those in rural communities, and an ap-
preciably higher rate in people of the northern
part of the United States as compared with
those in the southern states. These findings re-
main consistent in migrants from the northern
states to the southern states, and vice-versa, as
well as in migrants going to and from rural
and urban centers.
It is interesting that colon cancer occurs only
one tenth as frequently among the members of
the Bantu tribe in Southeast Africa as it does
with us. Yet cancer of the liver which accounts
for 50 per cent of all cancer deaths among the
Bantus, accounts for less than four per cent
in Europeans and North Americans.24 Again
we must search for environmental factors to ac-
count for this contrasting incidence. Scientists
speculate that it is probably due to the monoton-
ous diet of the Bantu tribesmen which is defici-
ent in milk and in meat in the early years. This
may be the predisposing cause that leads to
cirrhosis of the liver from which this form of
cancer appears to develop. The opportunity ex-
ists here to identify the environmental carcino-
gens and add another preventable cancer to our
list.
I will only mention the problem of the car-
cinogenic potentials of pesticides, of food addi-
tives— such as colors, flavors, emulsifiers, anti-
oxidants and fungal contaminants. Likewise,
cosmetics and certain medical preparations can
only be listed, because they are very complex
and much work needs to be done in this field.
From this discussion on preventable and
avoidable cancers, and on “cancers arising from
personal indifference,” it is obvious that epi-
demiological studies must be continued in the
search for causal environmental factors and that
we must promote public health measures for
the control of many cancers. We must educate
people about preventable cancers and that the
combating of certain deleterious social customs
and addictions, as well as economic factors, is
a necessary long term process requiring re-
search efforts in sociology, in psychology, and
in health education.
References
1. Medical Tribune and Medical News, Vol. 5, No.
56, June 10, 1964, page 20.
2. Prevention of Cancer. Report of a WHO Expert
Committee. World Health Organization Technical Re-
port Series No. 276, World Health Organization. Gen-
eva, 1964. Page 4.
3. Levin, M. L. The Epidemiology of Cancer. The
Fifth National Cancer Conference, Philadelphia,
Pennsylvania, September 17-19, 1964.
4. 1964 Cancer Facts and Figures. American Cancer
Society, New York, New York.
5. Wynder, E. L., Onderdonk, J., Mantel, N. An
Epidemiological Investigation of Cancer of the Blad-
der. Cancer 16: 1388-1407, November, 1963.
6. Pirchan, A., and Sickl, H.: Cancer of the Lung
in the Miners of Joachimov. Am. J. of Cancer. Vol. 16,
p. 681, 1932.
7. Ibid.
8. Prevention of Cancer. Report of a WHO Expert
Committee. World Health Organization Technical Re-
port Series No. 276, World Health Organization. Gen-
eva, 1964. Page 42.
9. Lynch, K. M., and Smith, W. A.: Pulmonary
Asbestosis: Carcinoma of Lung in Asbesto-Silicosis,
Amer. J. of Cancer 24: 56-64 (May) 1935.
10. Selikoff, Irving J.; Churg, Jacob; and Ham-
mond, E. Cuyler.: Asbestos Exposure and Neoplasia.
J. A. M. A. April 6, 1964, Vol. 188, pp. 22-26.
11. Moore, Condict: Smoking and Cancer of the
Mouth, Pharynx, and Larynx. J. A. M. A., Vol. 191,
No. 4, January 25, 1965, pages 283-286.
12. Christopherson, William M.; Mendez, Winifred
M.; Lundin, Frank E., Jr., and Parker, James E.: Can-
cer 18: 554-558, A Ten Year Study of Endometrial
Carcinoma in Louisville, Kentucky, May, 1965.
13. Medical Tribune and Medical News, Vol. 6, No.
8, January 18, 1965, page 13.
14. Ibid.
15. Stecker, Raymond H.; Devine, Kenneth D.;
Harrison, Edgar G., Jr.; Verrucose “Snuff Dipper’s”
Carcinoma of the Oral Cavity. J. A. M. A. Vol. 189,
No. 11, 838-840, September 14, 1964.
16. Brown, Robert L.; Suh, Jin Min; Scarborough,
J. Elliott; Wilkins, Sam. A., and Smith, Robert R.:
Snuff Dippers’ Intraoral Cancer: Clinical Character-
istics and Response to Therapy. Cancer, Vol. 18, No.
1, January, 1965, pages 2-13.
17. Rosenfeld, L., and Calloway, J.: Snuff Dipper’s
Cancer. Am. J. Surg. 106: 840-844, 1963.
18. Vincent, R. G., and Marchetta, F.: Relationship
of Use of Tobacco and Alcohol to Cancer of Oral
Cavity, Pharynx or Larynx. Am. J. Surg. 106: 501-
505, 1963.
19. Simons, J. N.; Masson, J. K., and Beahrs, O.
H.: Results of Radical Treatment for Intraoral Can-
cer. Am. J. Surg. 106: 819-825, 1963.
20. Martin, H. E., and Pflueger, O. H.: Cancer of
Cheek (Buccal-Mucosa); Study of 99 Cases with Re-
sults of Treatment at end of 5 years. Arch. Surg. 30:
731-747, 1935.
21. O’Conor, Gregory T.; Rappaport, Henry, and
Smith, Edward B.: Childhood Lymphoma Resem-
bling “Burkitt Tumor” in the United States. CANCER,
Vol. 18, No. 4, pages 411-417, April, 1965.
22. Dorfman, Ronald F.: Childhood Lymphosarco-
ma in St. Louis, Missouri, Clinically and Histological-
ly Resembling Burkitt’s Tumor. Cancer, Vol. 18, No.
4; pages 418-430, April, 1965.
23. Haenszel, William, and Dawson, Emily A.: A
Note on Mortality From Cancer of the Colon and Rec-
tum in the United States. Cancer, Vol. 18, No. 3,
pages 265-272, March, 1965.
24. J. A. M. A. Vol. 189, No. 11, page 38. Medical
News; Cancer Respects Neither Regions Nor Persons.
— 67 —
68
S.D.J.O.M. APRIL 1967 - ADV.
There are 7,520*
undetected diabetics in
South Dakota
Most of these are probably among patients over 40; the overweight;
relatives of diabetics, and mothers of large babies. By the time polyphagia, polyuria,
polydipsia, pruritus or other overt symptoms of diabetes appear,
damage may have been done that could have been minimized.
DEXTROSTIX® gives you a reliable blood-glucose estimate in 60 seconds.
Why Wait?
♦Based on Statistical Report, U.S. Dept. Commerce, ed. 86, and Fisher, G. F., and Vavra, H. M.:
Pub. Health Rep. 80:961 (Nov.) 1965.
Note; DEXTROSTIX is not meant to replace the more precise analytical laboratory
procedures such as needed in glucose tolerance testing.
AMES COMPANY, Division Miles Laboratories, Inc., Elkhardt, Indiana, U • S.A. 42867
Ames
1907 — 60TH AN N I VERSARY YEAR — 1 967
COMMENTARY
From
IIIIHB ■ ■
IIIIK
■ III II
■ III n
iliuoi
THE UNIVERSITY OF SOUTH DAKOTA
SCHOOL OF MEDICINE
NEWS PAGE
Beginning with this issue, the South Dakota
Journal of Medicine is setting aside a page for
news items of interest from the School of Medi-
cine. We wish to thank Dr. Van Demark and
his staff for their generosity and will use this
page to keep you well informed of the current
status of the school. Such subjects as new fac-
ulty members, grants received, curriculum im-
provements and new construction will be fea-
tured. Since the operation of a medical school
is beset with problems, we will probably have
a few words to say about these too. Such aspects
as the financial support of the school, faculty
salaries, selection of suitable medical students
and the recruitment of new faculty are all very
important in developing a modern progressive
institution and require the attention of all those
interested in medical education.
We hope our reflections and news items will
stir sufficient interest so that, occasionally,
some of you will respond with opinions and con-
structive criticisms. The object of this dialogue
with you is the significant improvement of
South Dakota’s School of Medicine.
Charles R. Gaush, Ph.D.
Chairman
Publications Committee
GRANTS AWARDED
Several grants have been awarded to the Med-
ical School and its faculty during the last few
weeks. A sum of $232,000 from the estate of
Ralph W. Parsons was bequeathed to the school
and the annual interest from this bequest, about
$10,000, will be used for research. Dr. Otto Neu-
haus received a $59,898 grant from PHS to con-
tinue his studies on plasma protein biosynthe-
sis. Senator McGovern announced the award of
$42,615 from PHS for institutional research and
a $26,369 grant from the National Fund for Med-
ical Education. The latter will be used for the
expansion and improvement of our closed cir-
cuit TV system for teaching medical students.
PHS has also announced the award of two re-
(Continued on Page 81)
NEW FACULTY
DR. BALEGNO DR. SHIMAMURA
President Edward Q. Moulton has announced
the appointment of two new faculty members
in the Departments of Biochemistry and Path-
ology.
Dr. Hector F. Balegno was appointed Assist-
ant Professor of Biochemistry after serving as
research associate at Wayne State University
School of Medicine in Detroit from 1965 to 1967.
Dr. Balegno is a native of Argentina and re-
ceived his Ph.D. from the University of Cordoba
(Argentina) in 1948. He has held a number of
appointments and was head of the Laboratory
of Internal Medicine at the University of Cor-
doba from 1949 to 1951. He was appointed re-
search associate at Wayne State Medical School,
a position he held from 1957 to 1962. He then re-
turned to Argentina as assistant professor in the
Institute for Cell Biology at Cordoba where he
served until he again returned to Wayne State
in 1965.
Dr. Balegno worked with Dr. Otto Neuhaus
at Wayne on the biosynthesis of plasma pro-
teins. Dr. Neuhaus was recently named Chair-
man of the Department of Biochemistry and
both investigators will continue their research
on the hepatic control of plasma protein biosyn-
thesis.
Dr. Tetsuo Shimamura, Assistant Professor of
Pathology, was born in Yokohama, Japan and
received his M.D. from the University of Yoko-
hama School of Medicine in 1959. He served a
rotating internship in the U. S. Army Medical
Command in Japan and also in the Bexar Coun-
(Continued on Page 81)
— 69 —
70
S.D.J.O.M. APRIL 1967 - ADV.
TO ASSURE YOUR AMA ACCOMMODATIONS AT THE 116th ANNUAL CONVENTION FILL IN THE COUPON BELOW:
AMA HOUSING BUREAU C/O THE ATLANTIC CITY CONVENTION BUREAU
16 CENTRAL PIER ATLANTIC CITY, NEW JERSEY 08401
FOR ROOM RESERVATIONS type\EixPchoiceRs DO YOU DESIRE AN AIR-CONDITIONED ROOM? Yes No_
Room will be occupied by:
1st
2nd
3rd
4th
5th •
6th
Please enter my reservation at the above hotel/motel for
Name
(Please print or type)
Street
City State Zip Code
Additional Occupants
Suite(s)
-□ @ $-
Date Arriving.
of all occupants for all rooms re-
served.
Single(s) Double(s) Twin(s)
□ @ $ □ @ $ □ @ $_
• If rate requested is not available,
next highest will be assigned.
• Be sure and specify time of arrival
as well as date.
• If you are an Industrial Exhibitor,
please specify firm name and list
• Please DO NOT send your request
directly to the hotel; it will only
delay your confirmation.
• Please make all changes and can-
cellations with the Housing Bureau.
AM _
Hour PM Departing
Confirmations will be mailed
up to June 7.
S.D.J.O.M. APRIL 1967 - ADV.
71
—avoid the lines—
REGISTER
NOW!
AM A 116 th ANNUAL CONVENTION
JUNE 18-22, 1967
ATLANTIC CITY - HOTELS & MOTELS
These rooms are available only through the AMA Housing Bureau.
MAP
NO.
BOARDWALK HOTELS
SINGLES
DOUBLES
TWINS
SUITES
1.
ABBEY NAC
10-12
12-14
16-20
2.
CHALFONTE-
(HEADQUARTERS HOTEL-
HADD0N FALL*
NO ROOMS AVAILABLE)
3.
CLARIDGE HOTEL*
10-26
14-30
58-88
4.
DEAUVILLE HOTEL*
14-20
16-28
45-130
5.
DENNIS HOTEL* P.AC
11-21
15-34
46-95
6.
HOLIDAY INN OF
ATLANTIC CITY*
12-20
17-19
16-24
40-82
7.
LA CONCHA HOTEL*
12-14
16-24
35-75
8.
MARLBORO UGH- BLENHEIM *
(Ocean Wing Only)
21-25
21-25
42
9.
MAYFLOWER HOTEL*
8-10
10-12
10-16
20-24
10.
PRESIDENT HOTEL* PAC
11-20
11-20
23-50
11.
SEASIDE TOWER HOTEL*
12
14-22
44-60
12.
SHELBURNE-
EMPRESS HOTEL*
(WOMAN’S AUXILIARY HEADQUARTERS)
13.
TRAYM0RE* P.AC
8-22
10-24
25-100
Map
No.
OFF-BOARDWALK HOTELS
Singles
Doubles
Twins
Suites
14.
CAROLINA CREST HOTEL.. PAC
10-12
12
12-14
15.
COLTON MANOR HOTEL*. P.AC
12-21
15-24
42-72
16.
EASTBOURNE HOTEL P.AC
7-9
10
11
17.
FLANDERS* ,N.AC
8
10
14
18.
STERLING P.AC
10-12
12-14
12-14
Map
No.
MOTELS
Singles
Doubles
Twins
Suites
19.
ACAPULCO MOTEL
12
14
16-20
20.
ALGIERS MOTEL*
12-14
14-16
12-20
45
21.
ALOHA MOTEL
14-16
14-28
22.
ASCOT MOTEL
14-16
14-18
23.
BALA MOTEL
12-18
16-24
24.
BARBIZ0N MOTEL INN
11-13
15
17-23
60
25.
BARCLAY MOTOR INN
20-28
20-30
55-65
26.
BLAIR MOTOR INN
12-16
16-22
27.
BURGUNDY MOTEL
12-16
16-26
28.
CARIBE MOTEL
10-12
12
14-18
29.
CAROLINA CREST MOTEL
14-16
14-16
30..
CASTLE ROC MOTEL
14
14-20
14-20
40
31.
CATALINA MOTEL
14-20
14-18
32.
COLONY MOTEL*
10-22
12-24
45-80
33.
COLTON MANOR MOTEL*
22-28
24-30
54-90
34.
CONTINENTAL MOTEL
14-16
14-20
35.
CORONET MOTEL
16-22
18-26
16-24
50-60
36.
CRILLON MOTEL
16-22
18-24
37.
CROWN MOTEL
14
16
18
38.
DEAUVILLE MOTEL*
14-24
16-32
100-130
39.
DENNIS MOTEL*
15-25
15-29
40.
DIPLOMAT MOTEL
10-12
14-24
30-36
41.
DUNES MOTEL
16
16-20
16-20
42.
EASTBOURNE MOTEL
16-20
16-24
43.
ELDORADO MOTEL
16
14-18
44.
ENVOY MOTEL
10
12
14-16
45.
FIESTA MOTEL*
14-16
16-22
35
46.
FOUR SEASONS MOTEL
14-18
18-24
47.
GALAXIE MOTEL
12-16
10-16
48.
HOWARD JOHNSONS*
14-18
14-18
18-30
44-90
49.
LA FAYETTE MOTOR INN*....
(CO-HQ
S HOTEL NO
ROOMS AVAILABLE)
50.
LINC0LN-R00SEVELT
BEACH MOTEL
16-18
14-20
18-28
51.
LOMBARDY*
12-24
14-26
52.
MALIBU MOTEL
12-14
16-20
53.
MARDI GRAS MOTEL
14-16
16-22
25
54.
MAYFLOWER MOTEL*
10-12
10-16
55.
MONTE CARLO
BEACH MOTEL
11
13-15
56.
MONTEREY MOTEL
14-16
14-16
18-20
57.
MOUNT ROYAL*
12-24
14-26
58.
PAGEANT
MOTOR INN MOTEL*
. 16-20
18-26
40-44
59.
PRESIDENT MOTEL*
13-22
13-22
60.
SEASIDE MOTEL*
14
16-22
61.
SHELBURNE-
EMPRESS MOTEL*
12-24
14-34
62.
SORRENTO MOTEL*
. 10-14
16-22
63.
STRAND OF
ATLANTIC CITY MOTEL*
. 10-14
13-17
64.
TEPLITZKY’S MOTEL
. 14
14-18
65.
TERRACE*
. 14
16-22
66.
TRINIDAD MOTEL
. 14-16
16-28
67.
TR0PICANA MOTEL
_ 8
10-12
14-18
20-24
*Restaurant and/or Coffee Shop on premises
All 100% Air Conditioned Except as Noted:
NAC (No Air Conditioning); PAC (Partial Air Conditioning)
I — I. I >1 ©_0_© rM~~r~L
HVLfnE — ■ — o I ({
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SOUTH DAKOTA
MINUTES OF THE COUNCIL MEETING
Sunday, January 22, 1967, 10:30 a.m.
Ramada Inn, Sioux Falls, S. D.
The meeting was called to order by J. P. Steele,
M.D., presiding chairman in the absence of E. T.
Lietzke, M.D. Those present for roll call were Drs.
J. J. Stransky, P. H. Hohm, E. J. Perry, J. P. Steele,
G. R. Bartron, A. J. Tieszen, J. A. Muggly, C. F. John-
son, C. E. Tesar, R. H. Quinn; Commission chairmen —
Drs. G. W. Knabe, Jr., and M. R. Cosand. Also pres-
ent were G. E. Tracy, M.D. and Richard C. Erickson.
Nominations for the Community Service Award
were opened. G. E. Tracy, M.D. of the Second District
nominated G. R. Bartron, M.D. Mr. Erickson read a
letter from E. H. Peters, M.D. of the Seventh Dis-
trict nominating Paul Reagan, M.D. for the award.
A secret ballot was taken. The results will be re-
vealed at the annual meeting.
Nominations for the Distinguished Service Award
were opened. Dr. G. E. Tracy nominated Mrs. William
Fish. Dr. C. F. Johnson nominated Dr. Frank Haas,
Dr. Paul Hohm and Mrs. Lucille Dory. A secret bal-
lot was taken, and the results will be revealed at the
annual meeting.
Dr. Hohm moved that the reading of the minutes
of the previous meeting be dispensed with inasmuch
as they have been published. The motion was second-
ed by Dr. C. F. Johnson and carried.
Commission Reports
Report of the Commission on Medical Service
REPORT OF THE CHAIRMAN, COMMISSION ON
MEDICAL SERVICE, SOUTH DAKOTA STATE
MEDICAL ASSOCIATION TO THE COUNCIL,
PREPARED FOR THE MEETING IN JANUARY, 1967
The Commission on Medical Service has had one
formal meeting since the last meeting of the Coun-
cil. Minutes of the meeting of the Commission are at-
tached herewith. Subsequent to this meeting, Mr.
Richard C. Erickson communicated with Irvin Bel-
zer, M.D., T.B. Control Officer, State Health Depart-
ment, Pierre, concerning free TB Clinics. Dr. Belzer
reported back to Mr. Erickson regarding his concept
of the development of free tuberculosis clinics in
this state.
Dr. Gerald Tuohy of Sioux Falls attended a meet-
ing of the South Dakota State Nursing Association in
Sioux Falls, October 28, 1966, as a representative of
this Commission. A copy of his report is enclosed
herewith.
The chairman of this Commission has been attend-
ing meetings of Heart-Cancer-Stroke Planning Com-
mittee. At the meeting November 19, 1966, the pro-
gram for the development of this activity was dis-
cussed in detail. It was announced that the application
for grant for funds for the planning committee is
now in Washington, D. C., and will be reviewed soon.
Subsequently it has been made known to the chair-
man of this Commission by Dr. Warren Jones that
the planning grant application has been looked upon
favorably and that the grant for about $54,000.00 for
the coming year has been approved. It was also an-
nounced that a coordinator or chairman for Cancer-
Heart-Stroke Program is being sought. Although this
person would preferably be a physician, if a quali-
fied individual in the paramedical area were avail-
able his application could be considered favorably.
An attractive salary for this person is in the offing.
Applications for this position can be sent to Mr. Rich-
ard Erickson at the South Dakota State Medical As-
sociation office, to Dr. Warren Jones at the School
of Medicine, University of South Dakota, or to mem-
bers of the Planning Committee.
Dr. J. A. Anderson will attend a meeting of the
Rural Health Committee of the A.M.A. in North
Carolina in mid-March of 1967 and Dr. J. B. Gregg
will attend the First National Congress on Socio-
Economics of Health Care in Chicago on January 22-
23, 1967. Reports of these meetings will be forth-
coming later.
This Commission recommends that the South Da-
kota State Medical Association take due and careful
notice of the plans of President Edward Q. Moulton,
University of South Dakota in regard to the devel-
opment of higher education in this state with special
reference to his thoughts in regard to the develop-
ment of the Medical School and most especially those
which pertain to the recruitment of teaching person-
nel by making salaries and other fringe benefits more
attractive and competitive with other institutions of
higher learning.
Respectfully submitted,
John B. Gregg, M.D., Chairman
Commission on Medical Service.
Minutes of the meeting of the Commission on
Medical Service of the South Dakota State Medical
Association in the office of the Dean, School of Medi-
cine, University of South Dakota, Vermillion, South
Dakota, on October 29, 1966. Commission members
present were Drs. Adams, Anderson, Amundson, Jah-
raus, Jones, Tracy, Willcockson, and Gregg. Also
present were President Edward Q. Moulton, Drs.
Brogdon, Knabe, and Lietzke and Mr. Richard C.
Erickson.
The meeting convened at 12:45 p.m. The primary
purpose of the meeting was to give the Medical
School Affairs Committee which is a function of the
Commission on Medical Service the opportunity to
meet President Moulton, to discuss with him his
ideas for the future development of the Medical
School and to offer to him the services of this com-
mission and ultimately the parent organization, the
South Dakota State Medical Association.
President Moulton reported that he hopefully en-
visions the ultimate development of a four year
medical school for this state. A sum of money has
been placed in the future budget of the University
for this purpose. President Moulton feels that there
should be appointed a study committee to delve into
this matter and consider it from all angles and then
report its feasibility.
The subject of the development of a two year
dental school for the State of South Dakota, the reas-
ons for its need, in conjunction with the presently
available facilities of the Medical School and those
to be developed in the future was also discussed. It
was also announced that there had recently been
started a dental technician training program at the
Medical School at the University of South Dakota.
President Moulton envisions an improvement in
the salary scale of the University of South Dakota,
throughout the entire University in an effort to help
develop and keep the teaching personnel in the Uni-
versity. A means to provide health-accident-life in-
surance program as a “fringe benefit” and plans to
improve retirement benefits were also discussed.
In conclusion President Moulton stressed the need
for cooperation between the State Medical Associa-
tion and the Medical School in the development of
the various programs to come.
The following matters of business were considered
by the Commission:
(1) The resolution regarding PKU testing, sub-
mitted by Dr. Heinrichs of Watertown was discussed.
Dr. Gerald Tracy brought with him a copy of the
article on this subject which Dr. Heinrichs has pre-
pared for the Journal of the South Dakota State
Medical Association. It was the feeling of the Com-
mission that Dr. Heinrichs should be commended for
his efforts to keep the physicians of this state ac-
quainted with the current thinking regarding this
subject. However, it was the consensus of the Com-
mission that where there are several methods of test-
ing for this situation and the ideas presented being
72 —
APRIL 1967
those of an individual physician, the Commission
should not endorse the article or the individual phys-
ician.
(2) Dr. Gerald Tuohy of Sioux Falls had attended
a meeting of the planning organization of the South
Dakota State Nursing Association in Sioux Falls on
October 26, 1966. He reported that plans are now be-
ing developed to enhance the nursing situation in
South Dakota. A formal report will be submitted
later.
(3) Dr. Jones gave a brief report concerning the
development of the Cancer-Heart-Stroke Program
for the State of South Dakota. The South Dakota
organization will be centered around the Medical
School and has voted to join with the State of Neb-
raska and possibly the State of North Dakota in this
program. Dr. Jones is a member of the planning or-
ganization by virtue of his position in the Medical
School. A representative of this Commission will be
seated with the planning organization. Recently the
chairman of the Commission has represented the com-
mission at several meetings of this organization. If
any other member of the Commission would like to
sit in on these planning activities, the chairman of the
Commission will be glad to step aside and allow him
to do so.
(4) The Manpower survey for this area which has
been sent to each member of this Commission was
not discussed other than briefly because much of the
material contained therein has been covered in the
discussion with President Moulton.
(5) It was announced that there will be a meeting
of the Rural Health Committee of the A.M.A. in
North Carolina in mid-March 1967. Dr. J. A. Ander-
son has volunteered to attend this meeting.
(6) Drs. Knabe and Jones discussed the affairs of
the Medical School. They reported there is harmony
and close cooperation in the Medical School. Dr.
Knabe reported that in its present concept he has
withdrawn his name from the list of potential candi-
dates for the position of Dean. It is his feeling that
as things now stand the position of Dean of the
Medical School entails disproportionately large
amounts of administrative work and not enough time
for matters pertaining to academic and practical med-
icine. He will prepare suitable recommendations with
his concepts as to how the Deanship can be made
more attractive to a potential candidate. It was re-
ported that several other candidates for the position
of Dean are being interviewed by the search com-
mittee.
Dr. Jones reported that there has recently been
some shortage of material in the dog laboratory. Dr.
Jones had contacted Senator Bartron regarding the
introduction of legislation to correct this matter. No
reply from Dr. Bartron had been received as of this
date. It was suggested to Dr. Jones that this matter
might wisely be deferred for the present because of
the anti-vivisectionists on a national level.
(7) Dr. Tracy discussed the development of a uni-
form physical examination blank for all of the in-
stitutions of higher learning in South Dakota. He
noted that the form now in use at the University of
South Dakota has met with almost universal accept-
ance throughout the state.
Because of changes in policy regarding immuni-
zation of children, by the American Academy of Pe-
diatrics, it will be necessary to update the recom-
mendation of the State Medical Association to the
physicians of South Dakota soon. Dr. Tracy will make
arrangements for this notification to be sent to the
physicians of this state.
There being no further business the meeting was
adjourned with the provision that minutes of the
meeting would be compiled by the Chairman of the
Commission and mailed to each Commissioner.
J. B. Gregg, M.D., Chairman
Commission on Medical Service
REPORT TO THE SOUTH DAKOTA ASSOCIATION
REGARDING PLANNED STUDY FOR NURSING
NEEDS IN THE STATE OF SOUTH DAKOTA
A meeting of medical and nursing representatives
from eight South Dakota organizations was held on
October 28, 1966. The purpose of this meeting was to
determine and define the projected needs in the
field of nursing in the state of South Dakota over
the next several decades.
It has been demonstrated in the state of South
Dakota that there are more endorsements of nursing
personnel outside the state than in the state. Reasons
given for this are:
1. husbands seeking employment other than in
South Dakota,
2. lack of clinical experience,
3. desire for master programs,
4. and the need for implementation of salary
increments.
For these reasons the planning committee decided
to study the program in depth and for these reasons
an organization called the South Dakota Planning
Council for Nursing Resources has been created. The
objectives of this study parallel those done in the
state of Illinois in 1965. These are:
1. to identify, assemble, and evaluate social, legal,
scientific and economic data relevant to nurs-
ing in South Dakota available from several
state organizations and agencies,
2. to identify and obtain data needed but not
available,
3. to document the nature of nursing at present
and to project what it should be in 1980,
4. to project the needs, both quantitative and qual-
itative, for the several kinds of nursing person-
nel including supervisory and administrative
for the variety of health services in South Da-
kota,
5. to recommend action offering the greatest likeli-
hood for overcoming shortages, increasing the
quality of nursing service and promoting the
most effective utilization of nurses available,
6. to suggest the role in implementing recommen-
dations of this study which appropriately should
be played by educational institutions, nursing
organizations, hospitals (individually and in as-
sociation) other health agencies, medical soci-
eties, physicians, the legislature, state govern-
ment, and citizens at large,
7. to culminate in the reports succinctly written
and so widely distributed as to contribute to
the program needed.
It is also felt that this commission should study
the attrition rate in nursing programs and determine
the kind of programs we need. The planning that is
done should be a continuing study updating, collating
of material and preparing of reports. It is felt that
this information can be correlated with statistics from
the Bureau of Health Manpower in the USPHS trends
toward specialization and also the trends in the
United States regarding physicians, dentists, and
other medical groups.
Sources of financial support for this study will
probably involve private funds and the possibility of
federal support will be explored.
Certain help can also be obtained from South Da-
kota State University which will supply office space,
transportation and a person who can search out data
in the state. It is the desire of this planning com-
mittee that the Medical Association in the state of
South Dakota contribute their support by sending a
representative to the planning committee and par-
ticipating with suggestions and criticisms on this
projected study.
SOUTH DAKOTA
Furthermore, sponsorship of this planning council
will be by all of the organizations: namely, the South
Dakota League of Nursing, the South Dakota Nursing
Association, the South Dakota Medical Association
and the South Dakota Board of Nursing and not any
individual group. It is felt that the findings of this
council should contribute greatly to the organiza-
tion and implementation of better nursing care in
South Dakota.
Follow-up meetings of the planning committee
are tentatively scheduled for December 1966.
Gerald F. Tuohy, M.D.
Dr. Tesar discussed the nursing report regarding
the two year R.N. training. Dr. Hohm requested that
Dr. Gregg and Dr. Tuohy give a further report on
the nursing study group at the next Council meeting.
Mr. Erickson discussed the scholarship funds for
University medical students. Dr. Hohm moved to
continue these scholarships for another year. The
motion was seconded by Dr. Johnson and passed
unanimously. The scholarships include two $100.00
scholarships for a freshman and a sophomore; a
$450.00 tuition scholarship for an incoming freshman;
and $200.00 travel expenses for the delegate to SAMA.
Dr. Knabe spoke on the need for the State Associ-
ation to have closer and continual planning with the
University Medical School. Dr. Knabe moved that
the Commission on Medical Service charge the sub-
committee on Medical School Affairs to study
problems of the present status and future growth
in medical and health education in the State of South
Dakota. The motion was seconded by Dr. Tesar and
passed unanimously. The report of the Commission
on Medical Service was accepted by the Council.
REPORT OF THE COMMISSION ON
SCIENTIFIC MEDICINE
No. 10 October 1, 1966
The meeting was called to order at the medical
association headquarters in Sioux Falls at 2:00 P.M.
by Chairman G. W. Knabe, Jr., M.D. Present for roll
call were Drs. G. W. Knabe, R. B. Leander, Bruce
Lushbough, S. W. Fox, E. H. Heinrichs, and Noel
deDianous. Also attending the meeting were Irvin
Belzer, M.D. and Mr. Mullen of the State TB Control
Program.
1. Mr. Mullen and Dr. Belzer discussed the TB
Program in South Dakota and answered questions
asked by the Commission members. Dr. Belzer in-
dicated that approximately 60 new cases are found
each year. They stated that the main problem in the
program is what happens to the patients after they
are diagnosed as tuberculosis cases. They have en-
countered a problem in receiving reports from the
physicians, but have not requested the physicians to
submit reports. It was suggested that an information-
al packet be prepared by the TB Control Office in
conjunction with the State Medical Association, for
distribution to the physicians in the state, outlining
the administrative procedures, so the doctors may
be informed of what they are expected to do. Infor-
mation in this packet will be submitted to the Com-
mission on Scientific Medicine for approval prior to
the mailing. It was suggested that Dr. Belzer and
Mr. Mullen be invited to appear at District Society
meetings to discuss the program with physicians in
the state.
2. The Diabeies Detection Drive for 1966 was dis-
cussed. The executive office was requested to obtain
information on the 9th District plan for distribution
to other districts as a commendable program. The
executive office is to obtain information from the
National Diabetes Association and send it to the Di-
abetes chairman in each district, or the District Sec-
retary. All programs are to be handled on the district
level. All districts that sponsor a Diabetes Week ac-
tivity are to be asked to submit a report to the ex-
ecutive office.
3. Dr. Heinrichs and Dr. Lushbough discussed
Heart Disease and Heart, Cancer and Stroke pro-
grams. Dr. Heinrichs discussed developments in the
proposed diagnostic center for South Dakota. Dr.
Heinrichs will prepare a short article for the Journal
on the importance of PKU testing on all newborns.
4. The Commission went over the format for the
annual meeting. The specialty groups are to be con-
tacted again regarding their selection of guest speak-
ers. It was decided to have four workshops on Tues-
day afternoon of the annual meeting including possi-
bly Cancer Chemotherapy, Psychiatry, Rheumatic
Heart Disease, and Tuberculosis and Pulmonary Dis-
eases. Dr. Heinrichs, Dr. Leander, Dr. Lushbough, and
Dr. deDianous will be in charge of arranging the
workshops. It was agreed that each workshop should
be limited to twenty five participants with advance
registration required.
The meeting adjourned at 4:45 P.M.
Respectfully submitted,
George W. Knabe, Jr., M.D., Chairman,
Commission on Scientific Medicine, SDSMA
REPORT OF THE COMMISSION ON
SCIENTIFIC MEDICINE
No. 11 January 4, 1967
The chairman apologizes for his apparent derelic-
tion of duties in recent months. This has been oc-
casioned by an increase in work when his associate
left and also a result of being assigned temporarily
new administrative duties. In this connection, he
acknowledges the timely and capable assistance of
those clinical pathologists who are freely donating
time to the teaching of medical students. Other mem-
bers of the commission have actively continued their
interest and work.
1. Tuberculosis Control: There continues to be mis-
understanding and lack of coordination of effort be-
tween physicians and the State Health Department
in this area. Dr. Irvin S. Belzer, Tuberculosis Control
Officer, advises that the purpose of establishing tu-
berculosis clinics in various centers of the state is to
serve patients who might otherwise neglect follow-
up care as well as to provide bases for the services
of field Tuberculosis Public Health Nurses. The Com-
mission will appreciate any cooperative efforts of Dr.
Belzer and Mr. Mullen to satisfactorily implement the
TB law. However, it continues to be disappointed by
the lack of response to its recommendations on this
program. SDSMA, after an extensive hospital and
laboratory survey and with the consultation of many
physicians, made recommendations for implementa-
tion of the TB Control and Treatment Law (S.D.J.
of Medicine, August, 1965, page 40). These were fa-
vorably received by the State Health Officer who
wrote in September 1965 that they would be present-
ed to the Public Health Advisory Committee and that
approval was likely. No action has yet been taken
on these and inquiries about fees, handling of diag-
nostic procedures, and other matters have not been
adequately answered. Continued study of adminis-
trative and medical methods for tuberculosis man-
agement is indicated by all groups concerned. The
following physicians will attend a USPHS Sympos-
ium on tuberculosis in Omaha January 11, 12, and
13: Drs. R. J. Zakahi, M. R. Ferrell, J. A. Cline, V. K.
Cutshall.
2. Diabetes: Dr. S. W. Fox has identified the phys-
icians in the various districts who are concerned
with detection programs. Organized clinics are most
applicable to large cities. It may be that screening
of high risk grouns mav be more rewarding. The
— 74 —
APRIL 1967
Commission’s role will be to encourage physicians to
sponsor detection programs and to collect and dis-
seminate information about successful drives.
3. Heart, Cancer, and Stroke Program: A progress
memorandum on the South Dakota-Nebraska pro-
gram has been sent by Dr. Warren L. Jones. Members
of the Planning Committee will attend a conference
on Regional Medical Programs called by H.E.W. in
Washington January 15-17, 1967.
4. Annual Meeting: Scientific sessions, June 5, 6,
1967 in Rapid City at the Surbeck Center of the
South Dakota School of Mines will follow the same
format used in the 1966 meeting.
Respectfully submitted,
George W. Knabe, Jr., M.D., Chairman,
Commission on Scientific Medicine SDSMA
Report of the Commission on Scientific Medicine
Dr. Knabe discussed the T.B. Control Program.
Dr. Stransky moved that the report of the Com-
mission on Scientific Medicine be accepted. The mo-
tion was seconded by Dr. Hohm and carried.
Report of the Commission on Communications
No written report was submitted by the Commis-
sion on Communications.
A discussion was held on the possibility of the As-
sociation sponsoring a booth at the State Fair. Dr.
Bartron moved that the State Association contact the
American Medical Association regarding a booth and
then establish this booth at the State Fair. The mo-
tion was seconded by C. F. Johnson, M.D., and passed
unanimously.
Commission on Liaison with Allied Organizations
M. R. Cosand, M.D., gave an oral report on the
work of the Commission on Liaison with Allied Or-
ganizations. He announced that $50.00 had been given
to the League of Nurses for their Health Careers pro-
gram.
A discussion was held on the labeling of prescrip-
tion drugs. The Commission recommended the Associ-
ation go on record as being in favor of labeling pre-
scription drug bottles. Dr. Muggly moved that the
oral report be accepted. The motion was seconded
by Dr. Hohm and carried.
Commission on Internal Affairs
SOUTH DAKOTA STATE
MEDICAL ASSOCIATION
INCOME
Budgeted
Proposed
Item
1966-67
1967-68
State Dues
$47,500.00
$48,000.00
Annual Meeting
_____ 9,000.00
9,000.00
Interest
400.00
400.00
Refunds & Misc.
1,000.00
1,000.00
Car Reimbursement
_____ 1,080.00
1,140.00
$58,980.00
$59,540.00
EXPENSES
Budgeted
Proposed
Item
1966-67
1967-68
Salary, Exec. Sec.
____$ 6,600.00
$ 6,600.00
Salary, Other
10,500.00
11,100.00
Social Security
700.00
600.00
Legal & Audit
_____ 1,200.00
2,600.00
Tele. & Telegraph
_____ 1.800.00
2,000.00
Office Suppl. & Equip.
__ 2,500.00
2,200.00
Dues & Subscriptions ___
_____ 1,500.00
1,400.00
Officers Travel
Physicians Travel
4,500.00
4,300.00
(Out-of-State)
Annual Meeting
_____ 8,000.00
8,500.00
Public Relations
_____ 3,500.00
3,000.00
Rent
. 3,000.00
3,000.00
Miscellaneous
100.00
100.00
Postage
. 2,200.00
2,200.00
Legis. Expense
_ 2,200.00
1,000.00
Benevolent Fund
400.00
400.00
Medical School End.
200.00
200.00
Ladies Auxiliary
800.00
800.00
Car Expense
_ 1,100.00
2,100.00
Clinical Pathology
800.00
600.00
Staff Travel
_ 4,500.00
4,500.00
Insurance ____
100.00
100.00
Employment Tax
25.00
100.00
Employee Relations
_ 1,600.00
1,600.00
$57,825.00
$59,000.00
Reserve
_ 1,155.00
540.00
$58,980.00
$59,540.00
JOURNAL INCOME
Budgeted
Proposed
Item
1966-67
1967-68
Advertising
.$18,000.00
$18,500.00
Subscriptions
_ 1,200.00
1,200.00
Miscellaneous
600.00
600.00
Refunds _
500.00
800.00
$20,300.00
$21,100.00
JOURNAL
EXPENSES
Budgeted
Proposed
Item
1966-67
1967-68
Salary, Editor
$ 720.00
$ 720.00
Salary, Staff
_ 2,400.00
2,400.00
Legal & Audit
50.00
50.00
Rent
300.00
300.00
Tele. & Telegraph
1 175.00
250.00
Social Security
100.00
110.00
Office Supplies
_ 16,255.00
16,870.00
Postage
200.00
300.00
Travel
100.00
100.00
$20,300.00
$21,100.00
GROUP LIFE — INCOME
Budgeted
Proposed
Item
1966-67
1967-68
Premiums
$30,000.00
$28,000.00
GROUP LIFE
— EXPENSES
Budgeted
Proposed
Item
1966-67
1967-68
Payment to
Insurance Company
$29,100.00
$27,300.00
Postage
50.00
50.00
Legal & Audit
50.00
50.00
Supplies
50.00
50.00
Balance to Surplus
750.00
550.00
$30,000.00
$28,000.00
BUILDING FUND — INCOME
Budgeted
Proposed
Item
1966-67
1967-68
Blue Shield Rent
$ 5,100.00
$15,996.00
Association Rent
_ 3,000.00
3,000.00
Journal Rent _
300.00
300.00
Bd. of Exam. Rent
600.00
600.00
Nurses Assoc. Rent
_ 1,080.00
OAA Rent
_ 2,400.00
$12,480.00
$19,896.00
BUILDING FUND — EXPENSES
Budgeted
Proposed
Item
1966-67
1967-68
Janitor & Repair
$ 2,300.00
$ 3,700.00
Utilities
_ 1,800.00
3,000.00
Interest
_ 2,600.00
3,396.00
Repayment of Loans
_ 2.780.00
5,300.00
— 75 —
SOUTH DAKOTA
Legal & Audit 1,000.00 1,000.00
Taxes & Insurance 2,000.00 3,500.00
$12,480.00 $19,896.00
Mr. Erickson discussed the proposed budget for
1967-68 for the State Association. Dr. Stransky moved
to accept the Association portion of the budget. The
motion was seconded by J. A. Muggly, M.D. and
passed unanimously.
A brief discussion was held on the Journal and
Group Life budget. P. H. Hohm, M.D. moved to ac-
cept these budgets and J. J. Stransky, M.D. seconded
the motion. It passed unanimously. Mr. Erickson dis-
cussed the Building Fund budget. Dr. Bartron moved
to accept the Building Fund portion of the budget.
The motion was seconded by Dr. Muggly and carried.
COMMISSION ON LEGISLATION AND
GOVERNMENTAL RELATIONS
October 1, 1966
Executive Office Sioux Falls, South Dakota
The meeting was called to order at 10:00 A.M. by
Chairman, Robert H. Quinn, M.D. Present for roll
call were the following physicians: R. H. Quinn, M.D.;
James Reagan, M.D.; C. E. Tesar, M.D.; R. W. Honke,
M.D.; R. J. Foley, M.D.; R. J. Bareis, M.D.; H. R.
Wold, M.D.; and Bill Church, M.D.
A discussion on the mail order drug situation in
South Dakota was held. The executive office was in-
structed to contact Mr. Harold Schuler of the Phar-
maceutical Association concerning the campaign of
the Senior Citizens Council of Washington, D. C. to
have prescriptions mailed to them for processing. At
the present time, the Pharmaceutical Association is
not planning to introduce any legislation at the 1967
session.
A discussion was held on the abortion legislation
in South Dakota. Dr. Orr indicated that the Ob-Gyn
Society would not be taking any stand on this type
of legislation. At the present time, it does not appear
that a bill will be introduced at the next session. It
was the feeling of the Commission that until such
time as the physicians in South Dakota can present
a united front on this matter, the Medical Associa-
tion oppose such legislation. If a bill is introduced in
1967, the Commission members are to be contacted
for recommendation. If necessary, a meeting could
be held in Pierre.
LSD Drug legislation from other states was dis-
tributed and considered by the Commission mem-
bers. Dr. Church moved that the Commission recom-
mend to the Council that the South Dakota State
Medical Association support legislation patterned af-
ter the Nevada law regarding the control of LSD.
The motion was seconded by Dr. Wold and carried.
Dr. Quinn discussed the possibility of members
of the Commission being available to travel to Pierre
if necessary to appear before committees. It was de-
cided that a meeting on a Tuesday, Wednesday or
Thursday, in Pierre would be most advantageous for
the Commission members during the legislative ses-
sion. Mr. Erickson will be asked to determine if a
meeting of this type is necessary.
A discussion on Title 19 was held. Mr. Erickson
gave a brief oral report of the present status of this
Plan. He indicated that the appropriation for opera-
tion of this program will be included in total funding
for the Welfare Department. Income limits and scope
of benefits of the program were discussed. It was
the feeling of the Commission members that there
should be a difference in income limits for the rural
population and urban population in this program. Dr.
Church moved that the executive office obtain a copy
of the Title 19 Plan which has been submitted to the
Kansas City HEW office for distribution to the Com-
mission members for study. The motion was seconded
by Dr. Bareis and carried.
Mr. Erickson discussed background information
on the proposed suicide law. Dr. Church moved that
the Commission on Legislation not recommend any
change in the suicide law at this time. The motion
was seconded by Dr. Wold and carried.
The proposed law for registration of Inhalation
Therapists was discussed. Dr. Foley moved that the
Commission make no recommendation concerning this
proposed law at the present time; that additional in-
formation be obtained from other states. The motion
was seconded by Dr. Tesar and carried.
The Commission considered the resolution passed
by the Council of the South Dakota State Medical
Association concerning separate billing. Dr. Tesar
moved that the Commission report to the Council that
additional legal opinions have been obtained and they
are concurrent with the opinion of our own South
Dakota legal advisor. If the Council wishes the Com-
mission to continue the study of this problem, they
will continue to do so. The motion was seconded by
Dr. Reagan and carried.
The meeting adjourned at 1:15 P.M.
R. H. Quinn, M.D. held a brief discussion on the
Resolution of the Council concerning separate billing.
Dr. Bartron moved to table consideration of the res-
olution. The motion was seconded by Dr. Quinn. The
motion passed. Vote — 7 for, 3 against.
Brief discussions were held on the LSD Bill which
Dr. Bartron has submitted to the Legislature, the
pharmacy bill and a gunshot wounds bill and a pro-
posed bill on dispensing medicines in offices at no
profit.
Dr. Knabe discussed the dog law requiring dogs
to be offered to the Medical School before they are
destroyed. Dr. Perry moved that the Commission on
Legislation lay the groundwork for a dog bill in the
next legislative session. Dr. Muggly seconded the mo-
tion and it passed unanimously.
Mr. Erickson suggested the Medical Association
hold a luncheon for legislators. Dr. Perry moved
that the luncheon be held. Dr. Johnson seconded the
motion and it passed unanimously. It was decided
that all legislators, the councilors, officers and com-
mission chairmen of the South Dakota State Medical
Association should be invited. Dr. Quinn suggested
that the Commission on Legislation also plan to meet
in Pierre at the time of the luncheon.
OLD BUSINESS
Mr. Erickson reported on activities in the execu-
tive office since the last Council meeting.
Dr. Quinn discussed Title 19 and meetings with
the Welfare Commission. No action was taken.
J. P. Steele, M.D., gave a report on the South Da-
kota Health Institute computer project. Dr. Stransky
recommended that the Council receive annual re-
ports on this project even if there is no progress. Dr.
Hohm moved that this report be accepted and that
the chairman keep the Council informed of future
developments. The motion was seconded by Dr.
Muggly and passed unanimously.
Dr. Hohm discussed the Heart, Cancer and Stroke
Program for the information of the Council. No action
was taken.
Mr. Erickson gave a report on the information re-
quested from the Harold Diers Company.
76 —
APRIL 1967
Harold Diers Company
Insurance Administrators & Counselors
Nebraska — South Dakota
506 City National Bank Bldg.
Omaha, Nebraska
December 15, 1966
Mr. Richard C. Erickson, Exec. Sec.
South Dakota State Medical Association
711 North Lake Avenue
Sioux Falls, South Dakota
Dear Mr. Erickson:
Here is the Insurance Report on the Group Plans
for the years 1964 - 1965 - 1966. We have not col-
lected all our premiums for 1966, so there might be
a slight variation in the total gross premiums.
Dr. Stransky has on file the years 1957 through
1963, Insurance reports, when he was Insurance
Chairman.
Total Premiums Loss Ratios
1964 $28,699.74 63.7%
1965 $31,332.20 25 %
1966 $32,899.05 67.2%
The 1957 through 1963 average was 69.9% and
the current average for 1964 through 1966, with an
average of 51.7%.
These figures do not include money spent for
Home Office expense, Agency Administration or re-
serves that are set up in the Company.
Although the total premium has not increased
substantially the participation has increased to ap-
proximately 60%. The reason for the low premium
and high participation is due to personal program-
ming with the individual Doctor on elimination per-
iods.
Thank you very much.
Sincerely,
Harold Diers & Company
by Bob Diers
RD/eg
NEW BUSINESS
Mr. Erickson discussed the Community Action Pro-
grams in connection with the Poverty Program. The
executive office is to send each councilor a copy of
the Pierre resolution regarding these programs for
their information.
A discussion was held on the proposed compulsory
generic drug legislation. It was recommended that
the SDSMA reaffirm the AMA’s stand on this matter
and so inform the American Pharmaceutical Associ-
ation.
Mr. Erickson discussed the usual and customary
fee basis in connection with the ODMC program. Dr.
Quinn recommended that as soon as negotiations on
fees are called for, we stress usual and customary
fees. It was recommended that we invite the ODMC
representatives to come and discuss fees with the Ex-
ecutive Committee at the time of the next Council
meeting. This action was moved by Dr. Hohm and
seconded by Dr. Stransky. It passed unanimously.
Mr. Erickson read a letter regarding admitting
patients to Yankton State Hospital only during office
hours except in the case of an emergency. No action
was taken.
A brief discussion was held on the Association’s
donation to the Science Fair. Dr. Bartron moved that
we donate $200.00. The motion was seconded by Dr.
Hohm and passed unanimously.
It was decided that the next Council meeting be
held at 11:00 a.m. on Sunday, April 2 in Sioux Falls
with the Executive Committee and the ODMC offici-
als meeting earlier that morning.
Dr. Perry moved the meeting be adjourned. The
motion was seconded by Dr. Stransky and passed
unanimously. The meeting adjourned at 4:00 p.m.
Togetherness....
. . . can be rough when epidemics of nausea and
vomiting strike a family. Emetrol offers prompt, safe relief. It is
free from toxicity1 or side effects2,3 and will not mask symptoms of
serious organic disorders.
1. Bradley, J. E., et al.: J. Pediat. 38:41 (Jan.) 1951.
2. Bradley, J. E.: Mod. Med. 20:71 (Oct. 15) 1952.
3. Crunden, A. B., Jr., and Davis, W. A.: Am. J. Obst.
& Gynec. 65:311 (Feb.) 1953.
O
RORER
R
WILLIAM H. RORER, INC.
Fort Washington, Pa.
Emetrol®
phosphorated carbohydrate
solution
emesis control
— 77 —
The Mediatric Age:
There is a growing senescent body of people on their
way to malignant inactivity, who sorely need your
interest and direction to help them back to a more active
and useful life. There are medicines too, designed to help.
One such has proved useful in clinical practice.
McNeill, A. J.: Clin. Med. 5:518 (Mar.) 1961.
“Mediatric (steroid-nutritional compound )
capsules, one a day, seem to give definite help
to debilitated patients”
Arnold, E. T., Jr.: Geriatrics 72:612 (Oct.) 1957.
“Nutritional and hormone bolstering of
function in the aged may have a useful place
in geriatrics .”
Morgan, A. E: Gerontologist 2:77 (June) 1962.
“A steroid-nutritional compound
(Mediatric) was used in 1 00 patients to
relieve some of the symptoms caused by
degenerative changes of aging ... This
therapy resulted in improvement of
75 per cent of the patients . .
“In diets which for any reason are restricted
in calories, enough of these substances
(B vitamins) may not be supplied . . . The use
of B and C vitamin supplements may then be
justified and indeed may be necessary.”
Morgan, A. F.: Gerontologist 2:77 (June) 1962.
“Intensive nutritional therapy is necessary,
especially in elderly people, to correct dietary
deficiencies created by large losses of protein,
vitamins and other nutrients.”
Riccitelli, M. L.: J. Am. Geriatrics Soc. 72:489 (May) 1964.
Mediatric*
Designed for the “metabolically spent”
Nutritional reinforcement for those who can’t
- or won’t- eat properly. . .balanced amounts of
estrogen and androgen to counteract declining
gonadal hormone secretion and its sequelae of
premature degenerative changes... mild
antidepressant for a gentle “mood” uplift...
The estrogen component in MEDIATRIC is
PREMARIN® (conjugated estrogens — equine),
the natural estrogen most widely prescribed for its
superior physiologic and metabolic benefits.
MEDIATRIC also provides nutritional reinforce-
ment—blood-building factors and vitamin supple-
mentation. It contributes a gentle “mood” uplift
through methamphetamine HC1.
Three different dosage forms— Liquid, Tablets, and
Capsules— offer convenience and variety.
MEDIATRIC Liquid
Each 15 cc. (3 teaspoonfuls) contains:
^Conjugated estrogens — equine (Premarin®) 0.25 mg.
Methyltestosterone 2.5 mg.
Thiamine HC1 5.0 mg.
Cyanocobalamin 1.5 meg.
Methamphetamine HC1 1.0 mg.
Contains 15% alcohol
MEDIATRIC Tablets and Capsules
Each MEDIATRIC Tablet or Capsule contains:
^Conjugated estrogens — equine (Premarin®) 0.25 mg.
Methyltestosterone 2.5 mg.
Ascorbic acid 100.0 mg.
Cyanocobalamin 2.5 meg.
Intrinsic factor concentrate 8.0 mg.
Thiamine mononitrate 10.0 mg.
Riboflavin 5.0 mg.
Niacinamide 50.0 mg.
Pyridoxine HC1 3.0 mg.
Calc, pantothenate 20.0 mg.
Ferrous sulfate exsic 30.0 mg.
Methamphetamine HC1 1.0 mg.
*Orally active, water-soluble conjugated estrogens derived from
pregnant mares’ urine and standardized in terms of the weight
of active, water-soluble estrogen content.
MEDIATRIC helps keep the older patient alert and active;
helps relieve general malaise, easy fatigability, vague pains in
the bones and joints, loss of appetite, and lack of interest
usually associated with declining gonadal hormone secretion.
contraindication: Carcinoma of the prostate, due to methyl-
testosterone component.
warning: Some patients with pernicious anemia may not
respond to treatment with the Tablets or Capsules, nor is
cessation of response predictable. Periodic examinations and
laboratory studies of pernicious anemia patients are essential
and recommended.
side effects: In addition to withdrawal bleeding, breast ten-
derness or hirsutism may occur.
suggested dosages: Male and female: 3 teaspoonfuls of
Liquid, 1 Tablet, or 1 Capsule, daily or as required.
In the female: To avoid continuous stimulation of breast and
uterus, cyclic therapy is recommended (3 week regimen with
1 week rest period— Withdrawal bleeding may occur during
this 1 week rest period).
In the male: A careful check should be made on the status
of the prostate gland when therapy is given for protracted
intervals.
supplied: No. 910 — MEDIATRIC Liquid, in bottles of 16
fluidounces and 1 gallon. No. 752 — MEDIATRIC Tablets,
in bottles of 100 and 1,000. No. 252 - MEDIATRIC Cap-
sules, in bottles of 30, 100, and 1,000.
Mediatric
steroid-nutritional compound
AYERST LABORATORIES, NEW YORK, N. Y. 10017 • Montreal, Canada
6C3G
Path C APsule
Submitted by the College of American Pathology in
connection with the South Dakota Society of Pathol-
ogists.
BLOOD UREA NITROGEN AND
NON-PROTEIN NITROGEN
It has been known for almost a century that
the nitrogen concentration of a protein free fil-
trate of blood or plasma is related to renal func-
tion. The non-protein nitrogen (NPN) fraction
consists of a heterogenous fixture of substances
of relatively small molecular size, which are not
precipitated by certain protein precipitants such
as tungstic acid. The chief constituents of NPN
are urea, creatinine, creatine, uric acid, amino-
acids, nucleotides, purines, polypeptides, gluta-
thione, ammonia and other unidentified frac-
tions2. The amounts of these substances vary
greatly between whole blood and plasma. Aver-
age normal NPN values for whole blood are usu-
ally between 20 mg.% and 40 mg.%2; serum
values are about 5 mg.% lower.
Urea is the most important NPN constituent
of blood. It is the chief end-product of protein
metabolism and ordinarily is excreted entirely
by the kidneys. In the normal individual the
blood urea nitrogen (BUN) is less than half of
the NPN concentration. Since many of the NPN
components are not excretory substances, as is
BUN, their concentrations do not rise with renal
insufficiency. Therefore, it makes more sense to
measure the one substance which makes up the
greater portion of circulating non-protein nitro-
genous material and which is directly related to
renal excretory capacity, than it does to esti-
mate the value of a heterogenous group of vari-
able nitrogenous substances. Hence the BUN is
a much superior test to the NPN.
Urea is formed in mammals from ammonia in
a complex cyclic pathway (the ornithine path-
way). Arginine, one of the amino-acids pro-
duced in many tissues, is hydrolyzed by the liver
enzyme, arginase, to urea and ornithine. It is
thus apparent that urea production is a func-
tion of the liver.
Urea has no useful function in the body and
in the process of excretion by the kidney the
plasma is filtered by the glomerulus, and urea
is excreted into the tubules where approximate-
ly 40% is again reabsorbed into the blood. The
clinical importance of urea arises from the fact
that an elevated concentration in the blood
stream may be associated with impaired renal
function.
It must be remembered that the BUN concen-
tration in the blood is determined by the bal-
ance between the rate of protein breakdown and
the rate of elimination by the kidney. The body
can utilize only a limited amount of protein for
synthesis or storage; hence, on high caloric,
high protein diets the excess is catabolized with
increases in blood urea values and excretion of
urea in the urine.
Addis has emphasized that the amount of pro-
tein in the diet has a profound influence on the
serum level of urea in normal persons as well
as those with kidney disease4.
Normal Range: The usually accepted normal
values for BUN are 9-17 mg.%1. This depends
largely upon protein intake; age and sex have
little influence although some authors have
found somewhat higher values in males and
older age groups3. The value in the normal in-
dividual depends chiefly upon the amount of
protein ingested and catabolized.
Increased Values: Elevated BUN values oc-
cur in a number of pathological conditions. The
cause may be increased production or decreased
elimination, due to impaired kidney function,
or a combination of the two processes. It is usu-
ally accepted that extensive renal disease must
be present before increased BUN values (azote-
mia) occur. With a consiant protein intake the
degree of azotemia is a function of the extent
and type of renal damage. However, an elevated
value provides no clue to the location of the
disease process; it can be glomerular, tubular or
extrarenal in nature. Values of 20-25 mg.%
should be viewed with suspicion but are not
unequivocal indication of kidney dysfunction.
In terminal chronic nephritis or severe acute
nephritis values of 200-300 mg.% may occur. In-
creased values are sometimes found in the ab-
sence of renal involvement. This occurs for ex-
ample when excessive amounts of protein are
broken down as is seen in cases of stress, my-
ocardial infarctions and gastrointestinal bleed-
ing.
Decreased Values: There are a few conditions
in which lowered BUN concentrations are
found. These are caused by decreased produc-
tion of urea and include: protein malnutrition
caused by diminished intake or impaired ab-
sorption, pregnancy during its later stages, and
in extensive liver damage.
Indications for the Test: Serum urea nitrogen
should be determined whenever diminished
— 80 —
APRIL 1 967
kidney function is suspected. It is a much more
meaningful test than the NPN and closely par-
allels the creatinine determination in use and
value. The latter test, however, is somewhat
more specific. It should be borne in mind that
in attempting to evaluate renal function, tests
such as the urea or creatinine clearance offer
more sensitive and quantitative information.
Material Needed for the Test: Serum (prefer-
ably fasting) 3 ml.
REFERENCES
1. Miller, A Text Book of Clinical Pathology, 6th Ed-
ition, p. 242.
2. Hoffman, The Biochemistry of Clinical Medicine,
2nd Edition, p. 268.
3. McKay, et. al., J. Clin. Invest., 4:295, 1927.
4. Addis, et. al., J. Clin. Invest., 26:869, 1947.
New Faculty (Contiuned from Page 69)
ty Hospital in San Antonio, Texas. Dr. Shima-
mura was assistant resident in Pathology at the
Washington University School of Medicine in
St. Louis and completed his residency at the
Baylor University School of Medicine.
Dr. Shimamura’s field of interest is kidney
diseases and he has a number of publications
concerning his recent work with experimental
glomerulonephritis and pyelonephritis. His cur-
rent research project deals with the role of auto-
immune mechanisms in chronic renal diseases.
C. R. G.
GRANTS —
(Continued from Page 69)
search grants to Dr. Earl B. Scott for the con-
tinuation of his studies on the histopathology of
amino acid deficiencies and an electron micro-
scopic study of deficiency diseases and aging.
The total amount awarded Dr. Scott was $24,550
for the current year. Dr. Charles Gaush received
a $6000 grant from the South Dakota Division
of the American Cancer Society for studies on
the cytoplasmic membranes of mammalian cells.
This amount included a new $3000 graduate stu-
dent fellowship in Microbiology.
C. R. G.
GENERAL PRACTITIONERS — Len-
nox, South Dakota has exceptional oppor-
tunity available for either single practice
or partnership arrangement. Lennox Clin-
ic building available; financial, profession-
al advantages; splendid surroundings in
Southeastern South Dakota; large area to
serve. Ideal for becoming established. In-
quiries, visits welcome. Contact City May-
or Fred Courey, chairman, Medical Serv-
ices Committee.
Two well-established general practition-
ers would like to help third physician in-
terested in having his own practice. We de-
sire close association without partnership.
Excellent chance to enjoy the benefits
of solo practice as well as the advantages
of association. No salary or other strings
attached.
Potential — Overpowering! New prac-
tice can gross $45,000 to $55,000 within
three years. Population of Sioux Falls 74,-
000 with large drawing area. One of the
real beauty spots in the Midwest. Hunting
and fishing year round within an hour’s
drive from the heart of town.
Sioux Falls is fortunate to have two gen-
eral hospitals which can accommodate up
to about 700 patients. There is also a Vet-
erans’ Hospital, in addition to a Crippled
Children’s Hospital.
Wonderful opportunity for the right
man. If interested, please reply to:
Don R. Salmon, M.D.
504 South Cleveland
Sioux Falls, South Dakota 57103
standard and custom
EVEREST & JENNINGS
FOLDING
WHEEL
CHAIRS
ALSO
WALKERS
CRUTCHES
PATIENT LIFTS
COMMODES
Rentals • Sales
Kreiser Surgical, Inc.
Sioux Falls Rapid City
— 81 —
Does she really care?
Is she alert, encouraged,
positive and optimistic
about getting completely
well soon?
Or has she given in to
the demoralizing impact
of confinement, disability
and dependency?
When functional fatigue
complicates convalescence,
Alertonic can help...
Pleasant-tasting Alertonic is pipradrol hydrochloride
—an effective cerebral stimulant whose gentle ana-
leptic action helps counteract the apathy and inertia
that can often delay convalescence— together with an
excellent vitamin and mineral formula, in a satisfy-
ing 15% alcohol vehicle.
Nothing fosters confidence and a sense of well-
being better than your own personal warmth, under-
standing and encouragement together with Alertonic
to help insure prompt response.
Adequate dosage is important: Prescribe Alertonic—
one tablespoonful t.i.d., 30 minutes before
meals . . . tastes best chilled.
And for your patient's sake, prescribe Alertonic
in the convenient, economical one-pint bottle.
Alertonic
Available Only On Prescription
Each 45 cc. (3 tablespoonfuls) contains: alcohol, 15% ; pipradrol hydro-
chloride, 2 mg.; thiamine hydrochloride (vitamin Bi) (10 MDR*), 10
mg.; riboflavin (vitamin B2) (4 MDR), 5 mg.; pyridoxine hydrochloride
(vitamin Bg), 1 mg.; niacinamide (5 MDR), 50 mg.; choline, t 100 mg.;
inositol,! 100 mg.; calcium glycerophosphate, 100 mg. (supplies 2%
MDR for calcium and for phosphorus) and 1 mg. each of the following:
cobalt (as chloride), manganese (as sulfate), magnesium (as acetate),
zinc (as acetate), and molybdenum (as ammonium molybdate).
♦Multiple of adult Minimum Daily Requirement supplied.
tThe need for these substances in human nutrition has not been established.
Indications: 1. Functional fatigue such as that often associated with: a
depressing life experience or stressful time of life; advancing years;
convalescence; limited activity or confinement. 2. Poor appetite and
vitamin-mineral deficiency as they occur in: patients having faulty eat-
ing habits; geriatric patients who are losing interest in food; patients
convalescing from debilitating illness or surgery.
Dosage: Adults, 1 tablespoonful; children (over 15 years old), 1 to 2
teaspoonfuls; children (4 to 15 years old), 1 teaspoonful. To be taken
three times daily 30 minutes before meals.
Contraindications: As with other drugs with CNS stimulating action,
Alertonic is contraindicated in hyperactive, agitated or severely anxious
patients and in chorea or obsessive compulsive states.
Side effects: Reports of overstimulation have been rare. Patients who
are known to be unduly sensitive to the effects of stimulant drugs should
be observed carefully in the initial stages of treatment.
(— v the wm. s. merrell company
Merrell ) Division of Richardson-Merrell Inc.
y Cincinnati, Ohio 45215
HUNTERS, SHOOTERS, GUN COLLECTORS
— TAKE NOTE!!!
There is now in operation nationally a well
organized and financed campaign to discredit
the fraternity of gun owners and users, and
those who deal in firearms, branding them as
socially irresponsible, deviates, and misfits.
Much of the present furor was precipitated by
the unfortunate incident wherein a maladjusted
individual assassinated the President of the
United States. Other circumstances involving
the abuse of firearms by psychopaths and by
careless individuals recently have added fuel to
the conflagration and directed public awareness
to the misuse of guns. Some of the abuse of guns
has resulted directly from the sensationalism
given by the press of this country to homicide
with firearms. Unfortunately, some of the more
outspoken nationally syndicated feature writers
have presented their appeal to the emotional
aspects of the problem, overlooking the concert-
ed efforts of the Izaak Walton League, the Na-
tional Rifle Association, the Boy Scouts, and
others to teach gun safety and to promote the
careful use of firearms. All of this has focused
attention on the subject of gun ownership and
use in the United States.
In the past year articles critical of guns and
their owners have been printed in several peri-
odicals, including Reader’s Digest. In the Nov-
ember 14, 1966, issue of Medical Economics there
appeared on pages 250-291 the condensation of
an article by Carl Barth, entitled “The Right to
Bear Arms.” It was most critical of the Nation-
al Rifle Association and those who in any way
use or handle guns. Because the thought con-
tent of this M.E. article was highly controversial
and slanted against the gun owner, it was re-
quested of the Editor of the M.E. by the under-
signed, that a rebuttal to the Barth article be
printed in the Letters to the Editor column. This
was not allowed.
Hunting and shooting is one of the largest
sports in South Dakota. The economy of this
state for many years has been geared to the in-
flux of pheasant hunters in the fall. Many phys-
icians and persons from other walks of life came
to South Dakota originally or returned here aft-
er an absence for education, military service, or
other adventure, primarily because of their love
of the out of doors and the excellent hunting
which this state offers to its residents. Many
young men now away from South Dakota for
various reasons look forward to their return so
that they can again enjoy the sporting facilities
available here. If the hunting and shooting facil-
ities here are removed or stringently tied by
law, making the use of firearms prohibitive, as
some might desire, a great incentive to come or
return to this state would be removed.
At the present time a South Dakota citizen
can purchase without difficulty a rifle or shot-
gun with which to hunt, target shoot, or to pro-
tect his property from predators. Although there
is no legal age limit upon the purchase of such
a gun, the gun dealers usually will not sell a
gun to anyone under 18 years. If he desires to
purchase a pistol, the state law specifies that
he be over 18 years of age or be accompanied by
his parent or guardian, signify his intent to pur-
chase at the dealer of his choice, and then sign
in triplicate a statement of intent to purchase.
He must then wait for two days before taking
possession of the weapon. One copy of the pur-
chase request goes immediately to the local po-
lice, one to the state of South Dakota, and the
— 84 —
APRIL 1967
other is retained by the gun dealer. In the event
that the purchaser of a handgun is bent upon
homicide, the two day wait usually makes dra-
matic changes in his plans. This arrangement in
regard to the purchase of firearms has existed
in this state for some time and has not led to
wholesale manslaughter with firearms. A per-
son who uses a pistol is required by law to have
a permit to carry the pistol, upon his person,
while he is carrying the pistol. This law serves
as a protective measure for the community as
a whole, but does not enact an undue hardship
upon the true, dedicated sportsman who likes to
shoot, but who desires to comply with the law
of the land.
In a recent bulletin of the Metropolitan Life
Insurance Company it was noted that in males
15-24 years of age firearms ranked third as the
cause of accidental deaths (4.5 deaths/100,000 at
15-19 years; 3.2/100,000 ages 20-24 years). In fe-
males firearms accidents resulted in 0.4/100,000
deaths in the same interval. Although the 15-19
year old males comprise less than 5% of the pop-
ulation, their gun accidents accounted for about
16% of the mortality resulting from the acci-
dental discharge of guns. This would suggest
that greater emphasis on gun safety is definite-
ly indicated. In the ten year interval 1952-53 to
1962-63 there was a decrease in the age adjusted
death rate from gun accidents.
If rigid, mandatory regulation of all guns is
to be avoided, it would appear that the hunters,
shooters, and gun owners are going to have to
police their own ranks. Education regarding
gun safety and accident prevention, hunter safe-
ty courses for all youths before they are allowed
to hunt or use firearms, and then constant sur-
veillance of these youngsters by parent or
guardian for a long time, will help decrease the
unfortunate effects of careless gun handling.
It is a foregone conclusion that some means
of preventing homicide with a destructive weap-
on is highly desirable. The Sullivan gun law in
New York, designed for this purpose, and the
gun laws in other states have not prevented
persons with criminal intent from obtaining and
using firearms or from committing murder with
other weapons. These laws have made it diffi-
cult for the private citizen who likes to shoot,
needs a weapon for the protection of his prop-
erty, or likes to collect guns, to obtain firearms.
It is also apparent that there is needed
some form of regulation of the interstate sale
of firearms through the mail, to deter those
who would stockpile weapons for pseudopatri-
otic organizations, to help prevent those who
have lengthy criminal records or records as
criminally insane, from obtaining firearms. This
is especially true of easily concealable weapons
such as pistols. The regulation of sale and use
of rifles, shotguns, and other weapons which
are not easily concealed can be handled effec-
tively on a state or local basis.
The hunters, shooters and gun collectors of
this state are going to have to concern them-
selves with this subject; help educate the public
regarding gun safety; participate in the activi-
ties of hunter safety courses, community gun
clubs, Izaak Walton League and other similar
organizations; make their thoughts and recom-
mendations known to their local and state of-
ficials, and Congressmen and Senators, if their
right to own, keep, and bear arms is to remain
unfettered by emotionally inspired, cumber-
some gun control laws.
J. B. Gregg, M.D.
Sioux Falls.
MEDICAL MOTION PICTURES, COLOR TV
TO AGAIN BE FEATURES AT AMA
ANNUAL CONVENTION
Medical motion pictures and color television
will be a feature of the Annual Convention of
the American Medical Association again this
year.
The Convention is to be held in Atlantic City
June 18-22, the Scientific Program at Convention
Hall and nearby hotels and the House of Dele-
gates at the Chalfonte-Haddon Hall Hotel.
Medical motion pictures have become an in-
tegral part of the Annual Convention program.
Movies are carefully screened and selected for
quality, content and diversity of subject mat-
ter. Some are chosen from the AMA library of
medical motion pictures while others are picked
from among films just completed. Several new
films are usually shown for the first time at the
Annual Convention. The total movie program is
thus planned to achieve both variety and cur-
rency.
Medical motion pictures will be presented
daily. At least five color television programs
will be presented live, on a closed circuit from
a Philadelphia hospital in cooperation with the
University of Pennsylvania School of Medicine.
Several of the Scientific Sections will parti-
cipate in this year’s color television program.
The entire Scientific Program for the 1967 An-
nual Convention will be published in the May
8 issue of the Journal of the American Medical
Association.
85
SOUTH DAKOTA
Xetter to Cditot—
February 7, 1967
South Dakota Medical Association
711 North Lake Avenue
Sioux Falls, South Dakota 57104
Dear Sirs:
I want to express our very deep gratitude to
your fine organization for the generous gift
provided for the three Science Fairs held in
South Dakota. The gift has been shared in equal
amounts with the University of South Dakota
and the School of Mines.
I am sure you realize that there are certain
expenditures in connection with the Science
Fair that cannot be sustained with state funds
and therefore, we must depend upon the inter-
est and generosity of organizations such as
yours. It is reassuring to find that the interest
in the Science Fair grows each year and we
have more entrants and the quality improves.
We are certain that the opportunity provided
by the Science Fair stimulates interest in the
individual participants and has a stimulating ef-
fect on the science program of the participating
schools. This interest becomes evident in the
community and has a broad impact.
You are part of a good team working for a
good cause and we are grateful to you.
Sincerely yours,
David F. Pearson
Assistant to the President
South Dakota State University
Brookings, South Dakota
CHILDREN'S MEMORIAL
HOSPITAL SEMINAR
Omaha, Nebraska
DISORDERS OF GROWING BONE
May 12-13, 1967
Victor McKusick, M.D.
Professor of Medicine
Johns Hopkins School of Medicine
David Smith, M.D.
Associate Professor of Pediatrics
University of Washington School of Medicine
DIABETES BOOK
DOING DOUBLE DUTY
The latest book published for diabetics is
Diabetes for Diabetics, by a practicing diabetol-
ogist, George F. Schmitt, M.D.
Doctor Schmitt clearly explains the cause and
treatment of diabetes, as well as its complica-
tions and problems, in simple terms which lay-
men can understand.
A large section on diet, including the most
complete food exchange lists ever published,
contains information on purchase, preparation
and selection of foods.
Many problems of daily living such as marri-
age, pregnancy, employment and insurance are
discussed. In addition, there are over two hun-
dred colored photographs.
The book is available at $5.95 prepaid from
the Diabetes Press of America, Inc., 30 S.E. 8th
Street, Miami, Florida 33131. Profits derived
from the sale of this book will be placed in a
fund primarily to send underprivileged diabe-
tic children to camp.
* i L'Oicft-no^S , ro
— 86 —
Almost all of the Poverty programs require some direction from the medical profession. These
programs include Head Start, Community Action, and others.
Money is being given to communities, some of it requiring matching by service or community
group agencies and individuals.
It is the policy of the Medical Association to hold to the principle of usual and customary fees
in any of these programs and I would urge you to hold to this. I feel that we must take part in some
of these programs, particularly in advisory capacities, in order that the medical programs will
have the proper professional direction.
Preston Brogdon, President
South Dakota State Medical Association
212-220 Realty Bldg.
Mitchell, So. Dak.
— 87 —
Ikti ij i/cur
MEDICAL ASSOCIATION
News Notes • Changes • Births • News
Pop's Proverb
The brilliant light of med-
ical knowledge becomes
but a feeble flicker when
it does not produce a cure.
The February 18, 1967, is-
sue of LIFE carried a most in-
teresting article on Symmet-
rel, Du Pont’s virus blocking
drug.
We feel fortunate to have
brought this drug to the at-
tention of South Dakota phys-
icians by means of advertising
in the January, February, and
March issues of this Journal.
^ ^ ^
R. J. Bareis, M.D., Rapid
City, recently attended a re-
gional conference of the Am-
erican Society of Internal
Medicine in New Orleans,
Louisiana.
Leaders of the society dis-
cussed all aspects of federal
health legislation.
ijs H5
New president of the Lem-
mon Chamber of Commerce
is C. A. Johnson, M.D. He was
named to the post at the or-
ganizational meeting of that
body held recently.
❖ * *
K. M. Illig, M.D., Pierre, re-
cently landed his single engine
plane safely on a highway in
Florida.
Dr. Illig put the plane down
on U.S. 10 in the Gainesville
area after the engine failed.
With him were his wife and
teen-aged daughter.
Announcement is made of
the American Cancer Soci-
ety’s 1967 Scientific Session to
be held May 3, 1967 at the
Sheraton-Dallas Hotel, Dallas,
Texas. No preregistration is
required, and there is no reg-
istration fee.
SjS ❖
A former Eagle Butte girl
has joined the staff of Temple
University in Philadelphia. Jo
Ann Haberman, M.D., earned
her degree in medicine from
the University of South Dako-
ta and Temple University.
She is now an assistant pro-
fessor at Temple and works
primarily on cancer research.
^ ^
Chris J. Moller, M.D., re-
c e i v e d the “Distinguished
Service” award presented by
the Dell Rapids Jaycees.
YOUR
CONTRIBUTION
TO THE
SOUTH DAKOTA
MEDICAL SCHOOL
ENDOWMENT
FUND
IS NEEDED
R. H. Hayes, M.D., Winner,
was honored recently by the
Winner Indian Council for his
past services to the Indian
people and for his recent serv-
ice in Viet Nam. Doctor Hayes
was given the honorary Indian
name of “Good Lance” and
was presented with a peace
pipe.
Since his return from Viet
Nam, Doctor Hayes has ad-
dressed many groups, showing
slides and describing his ex-
periences in that country.
^ ^ ^
A public forum on Mental
Retardation was held in Feb-
ruary in Omaha, Nebraska.
Spokesmen for programs in
South Dakota were Dr. Henry
V. Cobb, Chairman of the De-
partment of Psychiatry, the
University of South Dakota;
and Thomas Scheinost, Men-
t a 1 Retardation Planning,
State Department of Health.
The new officers for the
Sixth District Medical Soci-
ety are as follows:
President
F. D. Gillis, M.D.
Mitchell
Vice President
J. T. Berry, M.D.
Mitchell
Secretary-Treasurer
R. G. Gere, M.D.
Mitchell
H5 sf5
Ted Angelos, M.D., was re-
cently elected president of the
Canton Rotary Club. He will
take office in June.
— 88 —
H DAKOTA
.V' ' /
Additional information available
to the medical profession upon request.
Eli Lilly and Company
Indianapolis, Indiana 46206
700610
Each Pulvule® contains 65 mg. propoxyphene hydrochloride
227 mg. aspirin, 162 mg. phenacetin, and
32,4 mg. caffeine.
ANNUAL MEETING — SOUTH DAKOTA STATE MEDICAL ASSOCIATION
RAPID CITY, SOUTH DAKOTA JUNE 3, 4, 5, & 6, 1967
PARKE-DAVIS
for control of
allergic symptoms
some allergens are green
Whether the allergen is greenish or garish, unseen or
unknown, your patient can get symptomatic relief with
BENADRYL— the potent antihistamine with antispas-
modic action. INDICATIONS: Antihistaminic, anti-
spasmodic, antitussive, and antiemetic therapy.
PRECAUTIONS: Persons who have become drowsy
on this or other antihistamine-containing drugs, or
whose tolerance is not known, should not drive
vehicles or engage in other activities requiring keen
response while using this product. Hypnotics, sed-
atives, or tranquilizers if used with diphenhydramine
hydrochloride should be prescribed with caution
because of possible additive effect. Diphenhydramine
has an atropine-like action which should be con-
sidered when prescribing diphenhydramine hydro-
chloride. ADVERSE REACTIONS: Side effects are
generally mild and may affect the nervous, gastro-
intestinal, and cardiovascular systems. Drowsiness,
dizziness, dryness of the mouth, nausea, nervousness,
palpitation, blurring of vision, vertigo, headache,
muscular aching, thickening of bronchial secretions,
restlessness, and insomnia have been reported.
Allergic reactions may occur.
BENADRYL is available in Kapseals® of 50 mg. and
Capsules of 25 mg . 00867
The pink capsule with the white band is a trademark
of Parke, Davis & Company.
PARKE-DAVIS
ulrexin
tmxMmmii
llllllpll l
HW&D BRAND OFLUTUTRIN
mat m
3000 UNIT TABLETS
ii
IN THE
HAND SE
TREATMENT OF FUNCTIONAL DYSMENORRHEA
LECTED CASES OF PREMATURE LABOR AND 2ND
AND 3RD TRIMESTER THREATENED ABORTION
■ ■ .
In controlling abnormal uter-
ine activity, LUTREXIN, the
non-steroid “uterine relaxing
factor” has been found to be
the drug of choice by many
clinicians.
iillll
fl
f \
No side effects have been
reported, even when massive
doses (25 tablets per day) were
administered.
Literature on indications and
dosage available on request.
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
Volume XX May, 1967 Number 5
CONTENTS
The Diagnosis and Treatment of Rabies 19
Charles R. Gaush, Ph.D.; George W. Knabe, Jr., M.D.
Maternal Death During the Puerperium from Acute Cardiac
Failure Without a History of Heart Disease 26
C. A. Stern, M.D.
Death from Rabies in a Ten Year Old Boy 28
G. Robert Bell, M.D.
Clinicopathological Conference .... Sioux Valley Hospital .... 32
John F. Barlow, M.D.; Bernard J. Begley, M.D.
Minutes of the Council Meeting 36
PathCAPsule 50
Commentary from The School of Medicine,
University of South Dakota 59
Charles R. Gaush, Ph.D.
Editorial 62
Letter 64
This Is Your Medical Association 69
Second Class Postage Paid at Sioux Falls, South Dakota
Published monthly by the South Dakota Medical Association, Publication Office
711 North Lake Avenue. Sioux Falls, South Dakota 57104
rapy
500 mg. Caplets® q.i.d,
(initial aduit dose)
pyelitis?
urethritis?
ostatitis?
' . ,
any case,
usually gram-negative!
Indications: Urinary tract infections caused by gram-negative and some gram-
positive organisms.
Side effects: Mainly mild, transient gastrointestinal disturbances; in
occasional instances, drowsiness, fatigue, pruritus, rash, urticaria, mild
eosinophilia, reversible subjective visual disturbances (overbrightness of
lights, change in visual color perception, difficulty in focusing, decrease in
visual acuity and double vision), and reversible photosensitivity reactions.
Marked overdosage, coupled with certain predisposing factors, has produced
brief convulsions in a few patients.
Precautions: As with all new drugs, blood and liver function tests are advis-
able during prolonged treatment. Pending further experience, like most
chemotherapeutic agents, this drug should not be given in the first trimester
of pregnancy. It must be used cautiously in patients with liver disease or
severe impairment of kidney function. Because photosensitivity reactions have
occurred in a small number of cases, patients should be cautioned to avoid
unnecessary exposure to direct sunlight while receiving NegGram, and if a
reaction occurs, therapy should be discontinued. The dosage recommended
for adults and children should not arbitrarily be doubled unless under the
careful supervision of a physician. Bacterial resistance may develop.
When testing the urine for glucose in patients receiving NegGram, Clinistix®
Reagent Strips or Tes-Tape® should be used since other reagents give a
false-positive reaction.
Dosage: Adults: Four Gm. daily by mouth (2 Caplets® of 500 mg. four times
daily) for one to two weeks. Thereafter, if prolonged treatment is indicated,
the dosage may be reduced to two Gm. daily. Children may be given
approximately 25 mg. per pound of body weight per day, administered in
divided doses. The dosage recommended above for adults and children
should not arbitrarily be doubled unless under the careful supervision of a
physician. Until further experience is gained, infants under 1 month
should not be treated with the drug.
How supplied: Buff-colored, scored Caplets® of 500 mg. for adults, conve-
niently available in bottles of 56 (sufficient for one full week of therapy) and in
bottles of 1000. 250 mg. for children, available in bottles of 56 and 1000.
References: (1) Based on 23 clinical papers, 1512 cases. Bibliography on
request. (2) Bush, I. M., Orkin, L. A., and Winter, J. W., in Sylvester, J. C.:
Antimicrobial Agents and Chemotherapy — 1964, Ann Arbor, American
Society for Microbiology, 1965, p. 722.
nalidixic acid
a specific anti-gram-negative
eradicates most urinary
tract infections...
• Low incidence of untoward effects; no fungal
overgrowth, crystalluria, ototoxic or nephrotoxic
effects have been observed.
• “Excellent” or “good” response reported in
more than 2 out of 3 patients with either chronic
or acute gram-negative infections.1
HVfnfhrop
Winthrop Laboratories, New York, N. Y. 10016
*As many as 9 out of 10 urinary tract infections are now caused
by gram-negative organisms: E. coli, Klebsiella, Aerobacter,
Proteus. Paracolon or Pseudomonas2. . . However, infections of the
urethra and prostate caused by non-gonococcal gram-negative
organisms are believed to be less prevalent.
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
SUBSCRIPTION $2.00 PER YEAR
SINGLE COPY 20c
Volume XX
May, 1967
Number 5
STAFF
Editor
Assistant Editor
Associate Editor
Associate Editor
Associate Editor
Business Manager
Robert Van Demark, M.D Sioux Falls,
Judith Perkins Schlosser . Sioux Falls,
Robert Thompson, M.D. Yankton,
Gordon Paulson, M.D. Rapid City,
Gerald Tracy, M.D. Watertown,
Richard C. Erickson Sioux Falls,
S.
S.
S.
S.
S.
S.
D.
D.
D.
D.
D.
D.
EDITORIAL COMMITTEE
R. E. Van Demark, M.D., Chr
J. A. Anderson, M.D.
G. E. Tracy, M.D.
W. R. J. Kilpatrick, M.D.
Hugo Andre, M.D.
H. B. Munson, M.D.
R. F. Thompson, M.D.
John B. Gregg, M.D.
Sioux Falls,
S.
D.
Madison,
S.
D.
Watertown,
s.
D.
Huron,
s.
D.
Vermillion,
s.
D.
Rapid City,
s.
D.
... Yankton,
s.
D.
Sioux Falls,
s.
D.
PUBLICATIONS COMMITTEE
R. E. Van Demark, M.D., Gordon Paulson, M.D., Robert Thompson, M.D., W. T. Sweeney,
M.D.
OFFICERS
South Dakota State Medical Association
President .
President-Elect
Vice-President
Secretary-Treasurer
Executive Secretary
Delegate to A.M.A.
Alternate Delegate to A.M.A.
Chairman Council
Speaker of The House
P. Preston Brogdon, M.D.
John Stransky, M.D.
J. T. Elston, M.D.
A. P. Reding, M.D
Richard C. Erickson
A. P. Reding, M.D.
R. H. Quinn, M.D.
E. T. Lietzke, M.D.
J. P. Steele, M.D.
Sioux Valley Medical Association
President - C. J. McDonald, M.D
Secretary Daniel Youngblade, M.D.
Treasurer _Karl Wegner, M.D.
Mitchell, S. D.
_ Watertown, S. D.
... Rapid City, S. D.
Marion, S. D.
Sioux Falls, S. D.
Marion, S. D.
... Sioux Falls, S. D.
Beresford, S. D.
Yankton, S.D.
Sioux Falls, S. D.
Sioux City, Iowa
Sioux Falls, S. D.
THE DIAGNOSIS AND TREATMENT OF RABIES
Charles R. Gaush, Ph.D.
George W. Knabe, Jr., M.D.
School of Medicine
University of South Dakota
Vermillion, S. D. 57069
Rabies is an acute viral infection of the cen-
tral nervous system in humans. Although the
number of human infections has decreased from
47 in 1938 to 1 in 1965, the threat of infection is
always present due to the prevalence of the dis-
ease in neighboring states (Fig. 1). It can be seen
that many cases of rabies occur in nearly all
states to the south and east of South Dakota and
Nebraska, being particularly numerous in Iowa
and Illinois. In South Dakota, rabies infections
are most prevalent in skunks (697 cases), cattle
(333 cases), cats (194 cases) and dogs (136 cases)
as reported by the State University at Brook-
ings for the years 1949 to 1964 inclusive (7). The
physician is often called upon to treat wounds
and bites caused by animals suspected of hav-
ing rabies. His prompt and knowledgeable at-
tention to these cases will insure the continua-
tion of the low incidence of this disease in hu-
mans. The purpose of this paper is to review the
nature of the virus and of human and animal
infections, the treatment of infections and the
submission of specimens to diagnostic labora-
tories.
THE VIRUS.
Rabies virus is an elongated rod-shaped part-
icle with a diameter of 100 mu and a length of
about 250 mu (1). It has a filamentous internal
component with a diameter of 100 Angstroms
(8) which is surrounded by a membrane con-
taining small projections. With respect to struc-
ture, this virus is very similar to that of vesicu-
lar stomatitis, but there is no evidence of any
serological relationship to this or any other vi-
ruses. It is an RNA-containing virus (5) and
finger-like projections have been seen budding
from the surface of infected cells as the virus
emerges (1).
THE HUMAN DISEASE. (4, 10)
It is thought that the virus invades the nerv-
ous system soon after exposure, passing from
the site of infection to the CNS by way of the
peripheral nerves or perineural lymphatics. The
incubation period is usually from one to three
months, although it may be as short as 8 days
and as long as 8 months, depending on the in-
fecting dose and the site of exposure. The inci-
dence of rabies in unvaccinated individuals bit-
ten by rabid animals varies from 5 to 70 per
cent.
Clinical illness is heralded by 2 to 4 days of
prodromal symptoms such as headache, malaise,
nausea and vomiting, sore throat and fever. The
earliest symptom of diagnostic significance is
an abnormal sensation at the site of infection.
This occurs in 80% of cases and is manifest by
a tingling or paresthesia, often with a dull or
stabbing pain which radiates proximally or dis-
tally. The wound may be inflamed and excori-
ated usually by the patient’s scratching. The pa-
tient is then likely to demonstrate increasing
agitation with restlessness, nervousness, anxi-
ety and apprehension. He is sensitive to bright
lights and to noise. Spasmodic muscle contrac-
tions and convulsions may occur, and there are
usually disturbances of the autonomic nervous
system. The principal clinical symptom is the
inability to swallow fluids caused by painful
contractions of the pharyngeal muscles. The res-
piratory system may also be involved in these
spasms, producing apnea with gasping and cy-
anosis in severe cases. This, associated with a
generalized convulsion, is a common manner of
death. Depressive and paralytic symptoms oc-
cur if the patient survives the excitement stage,
although they may be interspersed with the
acute stage. Death then usually follows in 2 to
3 days but may be delayed for several weeks.
Once the clinical symptoms develop there are
no specific treatments other than those for
temporary symptomatic relief. Mortality at this
stage of the disease is virtually 100%. Past ex-
perience has shown that vaccines are usually
not effective if the incubation period is short.
19 —
FIG. 1. The number of rabies cases reported by state in 1965. From the “Annual
Rabies Summary,” Communicable Disease Center, USPHS, Atlanta, Georgia.
SOUTH
DAKOTA
— 20 —
MAY 1967
THE ANIMAL DISEASE.
Rabies is usually transmitted to humans by
domestic animals and to some extent by wild
animals. In the animal an encephalitis is pro-
duced which increases its tendency to bite, thus
perpetuating the disease. The incubation period
in dogs may be as short as 10 days but is usually
20-60 days and depends on the amount of in-
fecting virus. During the prodromal stage most
animals become nervous and apprehensive, al-
though some may become apathetic and die
without any disease symptoms. The onset of
disease is indicated by a desire to attack and
bite but hydrophobia does not occur in canine
rabies. Paralysis of the muscles of phonation oc-
curs in most infected animals and is indicated
by a change in their bark or growl. As the dis-
ease progresses the animal will probably show
muscular tremors, incoordination, convulsions,
paralysis, coma and death (4).
Dogs or other animals that appear nervous or
apprehensive and attack or bite anyone should
be captured (if possible), isolated and observed
for 10-14 days. If the animal is rabid, the above
symptoms will develop within this period and
death will usually occur within 3-5 days. If wild
animals are suspect, they may have to be killed
but the brain should not be damaged in the
process. The head of the animal should be
shipped on wet ice to a regional laboratory for
examination and confirmation of the disease.
Prevention of the disease in dogs is best ac-
complished by immunization with the Flury
LEP vaccine which is effective for three years.
This type of immunization is required by most
municipal statutes as a requisite for licensing.
LABORATORY DIAGNOSIS.
In the laboratory, several techniques are
available to establish a diagnosis from the ani-
mal specimens submitted. One of the best is the
fluorescent antibody test. Microscopic examina-
tion of the brain tissue for Negri bodies and iso-
lation of the virus from tissue specimens with
confirmatory neutralization tests provide addi-
tional evidence.
The complexity and difficulty of establishing
diagnosis by these procedures necessitates that
they be performed in laboratories routinely
handling rabies specimens. In some cases where
the specimen has undergone decomposition due
to delay in shipment it may be necessary to re-
sort to histologic study by procedures custom-
arily employed in pathologists’ laboratories.
Therefore, tissue unsuitable for the customary
immediate diagnostic procedures may yield in-
formation by histologic examination. If consul-
tation with the laboratory indicates that the
specimen is unsuitable it should be placed in
10% formalin, making certain that the forma-
lin is allowed to permeate through the entire
brain by making suitable non-deforming incis-
ions. It can then be referred to a local patholo-
gist who can examine it for evidence of enceph-
alitis and inclusion bodies. In some cases it may
be desirable to examine other organs from a
suspected animal since some other disease may
be found to be the cause of the animal’s be-
havior.
TREATMENT OF PERSONS
EXPOSED TO RABIES.
In treating persons exposed to rabid animals,
local treatment of wounds has been employed
for a number of years. In view of several ani-
mal experiments (2), this is a very effective
method for preventing the disease. The first
consideration by the patient in the treatment
of animal bites is the immediate washing and
flushing of the wound. Water alone may suffice
but soap or detergents are preferred since the
virus is rather susceptible to these agents. In an
experiment with guinea pigs (2) only 5% of the
animals died if the wounds were washed where-
as 90% of the controls died. Further treatment
of wounds by the physician would include
washing with a 1 or 2% aqueous Zephiran® sol-
ution, or a 20% soap solution. Topical applica-
tion of antirabies serum is also useful as is the
use of antibiotics or antitetanus procedures.
Thorough cleansing, topical treatment with an-
tiserum and injection of antiserum under and
around the wound is the treatment of choice in
severe bites; in addition, a full course of rabies
vaccine should be given. The vaccine used
should always be of the inactivated type such
as the Semple vaccine or the duck embryo vac-
cine. The Semple vaccine virus has been inac-
tivated by heat while the duck embryo vaccine
virus has been inactivated by beta-propiolac-
tone. Live virus vaccine such as the Flury HEP
chick embryo vaccine is not indicated in the
treatment of persons exposed to the natural vi-
rus. This type of vaccine is suggested for the
immunization of those who work with or are ex-
posed to rabies virus in their work.
In cases of severe bites it is desirable to ad-
minister both the anti-rabies serum and the
vaccine. The passive immunization by the anti-
serum provides short term protection by neu-
tralizing the infecting virus while the vaccine
elicits the formation of additional antibody.
Since the antiserum administered will also
neutralize some of the vaccine virus, maximum
21 —
SOUTH DAKOTA
antibody titers are often not observed until the
21st day. In these situations it is recommended
that a booster be given 10 and 20 days after the
last inoculation of the standard series. Habel
(3) and Koprowski (6) found that in animal ex-
periments the use of antiserum and vaccine is
much more effective than either antiserum or
vaccine alone.
In case of exposure to rabies by any means,
it is the responsibility of the physician to deter-
mine the type and duration of treatment as this
will depend on the circumstances involved.
Since these are quite variable, a standard pro-
cedure is not feasible and the recommendations
of the WHO Expert Committee on Rabies (11)
are the best guide. These procedures are listed
in Tables I and II.
SHIPMENT OF SPECIMENS.
It is very important that animals suspected of
having rabies be captured and confined for ob-
servation if at all possible. If the animal is
rabid, death will usually occur in a few days.
The head should be removed and submitted to
a laboratory for examination. The following re-
gional laboratories are equipped for the diag-
nosis of rabies in South Dakota:
1. Specimens from west of the Missouri
River:
Division of Laboratories
State Department of Health
Pierre, South Dakota 57501
Questions concerning specimens should be
directed to Mr. Ben E. Diamond, Director of the
above laboratory, who can be reached at CA4-
5911, extension 368 or 369; after hours call CA4-
7863.
2. Specimens from east of the Missouri
River:
Department of Veterinary Sciences
South Dakota State University
Brookings, South Dakota 57006
Dr. G. S. Harshfield, Director, can be reached
at 692-6111, extension 372 to answer any proced-
ural questions.
There has been some confusion regarding the
shipment of fresh specimens and in order to
clarify matters two important factors should be
kept in mind:
1. Avoid deterioration of the specimen.
2. Avoid the possibility of infecting others
who may handle the specimen enroute.
TABLE I
Local Treatment of Wounds Involving Possible Exposure to Rabies
(1) Recommended in all exposures
(a) First-aid treatment
Immediate washing and flushing with soap and water, detergent or water alone (recommended procedure
in all bite wounds including those unrelated to possible exposure to rabies).
(b) Treatment by or under direction of a physician
(i) Adequate cleansing of the wound.
(ii) Thorough treatment with 20% soap solution and/or the application of a quaternary ammonium com-
pound or other substance of proven lethal effect on the rabies virus. 1
(iii) Topical application of antirabies serum or its liquid or powdered globulin preparation (optional).
(iv) Administration, where indicated, of antitetanus procedures and of antibiotics and drugs to control in-
fections other than rabies.
(v) Suturing of wound not advised.
(2) Additional local treatment for severe exposures only
(a) Topical application of antirabies serum or its liquid or powdered globulin preparation.
(b) Infiltration of antirabies serum around the wound.
1 Where soap has been used to clean wounds, all traces of it should be removed before the application of
quaternary ammonium compounds because soap neutralizes the activity of such compounds.
Zephiran, in a 1% concentration, has been demonstrated to be effective in the local treatment of wounds
in guinea pigs infected with rabies virus. It should be noted that at this concentration quaternary ammonium
compounds may exert a deleterious effect on tissues.
Compounds that have been demonstrated to have a specific lethal effect on rabies virus in vitro (different
assay systems in mice) include the following:
Quaternary Ammonium Compounds
0.1% (1:1000) Zephiran
0.1% (1:1000) Cetylamine
1.0% (1:100) Hyamine 2389
Other substances
43 — 70% ethanol; tincture of thiomersal; tincture of iodine and up to 0.01% (1:10,000) aqueous solutions of io-
dine; 1% to 2% soap solutions.
1.0% (1:100) Phemerol
1.0% (1:100) SKF 11831
1.0% (1:100) Diaparene
— 22 —
MAY 1967
TABLE II
Specific Systemic Treatment
Status of biting animal (irrespective of
Nature of exposure
whether vaccinated or not)
Recommended treatment
of Patient
At time of
During observation period
exposure
of ten days
I. No lesions; indirect
Rabid
None
contact
II. Licks:
(1) unabraded skin
Rabid
None
(2) abraded skin,
(a) healthy
Clinical signs of rabies or
Start vaccine 1 at first signs
scratches and un-
proven rabid (laboratory)
of rabies in the biting ani-
abraded or abraded
mal
mucosa
(b) signs sugges-
Healthy
Start vaccine 1 immediately;
tive of rabies
stop treatment if animal is
normal on fifth day after
exposure
(c) rabid, es-
Start vaccine 1 immediately
caped, killed
or unknown
III. Bites:
(1) mild exposure
(a) healthy
Clinical signs of rabies or
Start vaccine 1.2 at first
proven rabid (laboratory)
signs of rabies in the biting
animal
(b) signs sugges-
Healthy
Start vaccine 1 immediately;
tive of rabies
stop treatment if animal is
normal on fifth day after
exposure
(c) rabid, es-
Start vaccine 1-2 immediate-
caped, killed
or unknown
ly
(d) wild (wolf,
Serum2 immediately, fol-
jackal, fox,
lowed by a course of vac-
bat, etc.)
cinel
(2) severe exposure
(a) healthy
Clinical signs of rabies or
Serum.2 immediately; start
(multiple, or face,
proven rabid (laboratory)
vaccine 1 at first sign of ra-
head, finger or neck
bites)
bies in the biting animal
(b) signs sugges-
Healthy
Serum.2 immediately, fol-
tive of rabies
lowed by vaccine; vaccine
may be stopped if animal is
(c) rabid, es- \
normal on fifth day after
caped, killed j
or unknown /
exposure
(d) wild (wolfA
Serum2 immediately, fol-
jackal, pariahf
dog, fox, bat,\
etc.) 1
lowed by vaccine 1
1 Practice varies concerning the volume of vaccine per dose and the number of doses recommended in a given
situation. In general, the equivalent of at least 2 ml of a 5% tissue emulsion should be given subcutaneously
daily for 14 consecutive days. Many laboratories use 20 to 30 doses in severe exposures. To ensure the produc-
tion and maintenance of high levels of serum-neutralizing antibodies, booster doses should be given at 10 days
and at 20 or more days following the last daily dose of vaccine in all cases. This is especially important if anti-
rabies serum has been used, in order to overcome the interference effect.
2 In all severe exposures and in all cases of unprovoked wild animal bites, antirabies serum or its globulin
fractions together with vaccine should be employed. This is considered by the Committee as the best specific
treatment available for the post-exposure prophylaxis of rabies in man. Although experience indicates that
vaccine alone is sufficient for mild exposures, there is no doubt that here also the combined serum-vaccine
treatment will give the best protection. However, both the serum and the vaccine can cause deleterious reac-
tions. Moreover, the combined therapy is more expensive; its use in mild exposures is therefore considered op-
tional. As with vaccine alone, it is important to start combined serum and vaccine treatment as early as pos-
sible after exposure, but serum should still be used no matter what the time interval. Serum should be given
in a single dose (40 IU per kg of body weight) and the first dose of vaccine inoculated at the same time. Sensi-
tivity to the serum must be determined before its administration.
— 23 —
SOUTH DAKOTA
In order to avoid deterioration, the specimen
should be packed in wet ice using 5 times the
volume of the specimen during the hot summer
months. "Dry ice is not recommended because
time is wasted waiting for the brain to thaw and
freezing disrupts tissue architecture which
makes histological examination difficult. It
should be sent to the laboratory with dispatch
using the most rapid means of transportation
available. If possible the specimen should be de-
livered in person if the driving distance is with-
in 2-4 hours. The State Highway Patrol, Game
Wardens or other state officials may be avail-
able to transport the specimens. They are some-
times sent by bus and it is also permissible to
mail the specimen if it is properly packaged.
The post office only prohibits the mailing of
live animals suspected of or having rabies (9).
Proper packaging for mailing is necessary to
prevent deterioration and also to avoid the pos-
sibility of infecting postal employees and con-
taminating mail. Postal authorities state that
the sender is liable for any damage due to im-
properly packaged specimens (9).
If the specimen is small enough it may be
placed in a wide-mouth jar which is then sealed
with some type of water-proof tape. The jar
should be placed in a can with a tight closure
(such as a lard can) containing wet ice and saw-
dust, vermiculite or some other insulator. This
material should be wet with a disinfectant or
soap solution so it can serve as both insulation
and a trap should the specimen container leak.
The can should also be sealed with water-proof
tape. The can should then be placed in a sturdy
cardboard box containing more insulation or
absorbent material to soak up the water that
will condense on the side of the can. This is im-
portant since the post office may not accept or
send a package that is leaking or wet. Physi-
cians may find it desirable to keep a suitable
container and packing materials on hand in
case of sudden need. A prominent label should
be attached to the box with the words: “RUSH-
RABIES SUSPECT.” If the specimen is large,
it may be sealed in a double plastic bag instead
of being placed in a glass jar. These procedures
apply to specimens sent by parcel post, bus or
railway express. The most important factors
are that the specimen must be shipped in a
double-sealed container enclosed within a
sturdy box and it must be kept on ice. The pres-
ently available laboratory methods can not be
*Cans of refrigerant such as used for camping are
convenient.
used with confidence if the specimen has de-
teriorated.
REFERENCES
1. Davies, M. C., M. E. Englert, G. R. Sharpless and
V. J. Cabasso 1963 Electron microscopy of rabies
virus in cultures of chicken embryo tissues. Vir-
ology 21:642-651.
2. Dean, D. J., G. M. Baer and W. R. Thompson 1963
Studies on the local treatment of rabies-infected
wounds. Bull. WHO, 28:477-486.
3. Habel, K. 1945 Seroprophylaxis in experimental
rabies. Pub. Health Rep., 60:545-560.
4. Johnson, H. N. Rabies Virus in “Viral and Rickett-
sial Infections of Man,” by Horsfall and Tamm,
4th ed., 1965, J. B. Lippincott Co., Philadelphia.
5. Kissling, R. E. and D. R. Reese 1963 Antirabies
vaccine of tissue culture origin. J. Immunol., 91:
362-368.
6. Koprowski, H. and J. Black 1954 Studies on chick
embryo-adapted rabies virus. J. Immunol., 72:503-
510.
7. McNeilly, G. and G. S. Harshfield 1965 What you
should know about rabies. U. S. Dept. Agric. Pub.
SFS 280.
8. Pinteric, L., P. Fenje and J. D. Almeida 1963 The
visualization of rabies in mouse brain. Virology,
20:208-211.
9. Sheridan, R. L. 1966 U. S. Post Office Department,
Washington, D. C. Personal Communication.
10. Wagner, R. R. 1966 Rabies, p. 1720-1722. In T. R.
Harrison, [Ed.], Principles of Internal Medicine.
McGraw-Hill, Inc., New York.
11. World Health Organization, Technical Report Se-
ries #321, 1966.
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— 24 —
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MATERNAL DEATH DURING THE PUERPERIUM
FROM ACUTE CARDIAC FAILURE WITHOUT
A HISTORY OF HEART DISEASE
By
C. A. Stern, M.D.
Sioux Falls, South Dakota
The author wishes to express his appreciation to
William D. Johnson, Director, Division of Public
Health Statistics, South Dakota State Department of
Health; Madonna Clark, R.R.L., McKennan Hospital,
and Harriet Smith, R.R.L., Sioux Valley Hospital.
The dramatic reduction in all of the leading
causes of maternal mortality is one of the great
medical accomplishments of this century. With
this decrease in the number of maternal deaths,
there has been a shift or realignment in the rel-
ative importance of the etiological factors in-
volved. Deaths from cardiac disease, although
showing a decline numerically, have not shown
the same proportionate drop when compared
to the other causes of maternal mortality. If
“direct” obstetrical deaths such as those from
hemorrhage and toxemia are eliminated, then
fatalities from cardiac disease will rank as one
of the number one “killers” of the puerperial
patient.
In the decade 1955 to 1965 deaths from all car-
diac causes, including embolic and thrombotic
vascular disease, were second only to hemorr-
hage as the leading factor in maternal deaths in
the State of South Dakota. “Direct” cardiac dis-
ease with right or left heart failure accounted
for one half (10) of these deaths; however an in-
teresting finding was that in about 40% of the
deaths due to heart failure there was no known
previous history of cardiac disease and no di-
agnosis of heart disease was made except as a
terminal event.
The clinical picture of these patients is re-
markably similar; the sudden appearance in an
elderly multipara of acute progressive cardiac
failure usually of the right heart with death oc-
curring in the puerperium despite adequate
medical treatment. There is no known history
of cardiac, renal or hepatic disease and most pa-
tients, as far as known, had a normal prepartum
course. There appears in most cases a few clin-
ical or symptomatic warnings of prognostic im-
portance. These are: (1) a history of progressive
fatigue, (2) a history of a U.R.I. with a non-pro-
ductive cough, (3) tachypnea or dyspnea which
is progressive, and (4) tachycardia which is con-
sistent and present at rest. These symptoms and
signs are, of course, those which may be found
in early cardiac failure in any patient, but in
the multipara and during the puerperium they
have an ominous significance. A short case his-
tory of two of these patients is given below to
illustrate the sequence of events in the clinical
history:
CASE NUMBER ONE:
This 39 year old gravida 4 para 3 was ad-
mitted to Sioux Valley Hospital 6/2/60 from a
nearby community hospital. The diagnosis by
her physician was “pneumonitis.” The prepar-
tum and past history was not significant except
for a complaint of fatigue for an undetermined
period, and recurrent episodes of cystitis. One
day prior to admission she was stated to have
developed a temperature of 102 F. and a W.B.C.
of 17,000. At this time the patient was complain-
ing of a non-productive cough and moderate
dyspnea.
The patient was seen at 3:30 A. M. by the
medical resident, who reported that she ap-
peared somewhat dyspneic and cyanotic but in
no acute distress and had negative physical
findings including examination of the chest.
At 9:00 A. M. the patient’s condition became
critical with the development of an acute pul-
monary edema. The liver was palpable two
fingers below the costal margin and the chest
was filled with moist rales. The abdomen was
the size of a term pregnancy with the fetus in
an OLA position. Fetal heart tones were good
— 26 —
MAY 1967
and in the normal range. The temperature was
100.8, the pulse 120 to 140 and the blood pres-
sure 150/70. Shortly after intensive treatment
was started for acute right failure by the medi-
cal consultant, the patient ruptured her mem-
branes spontaneously, and went into a precipi-
tate labor. A viable term infant was delivered
with low forceps under local anesthesia with
the patient in a semi-sitting position and receiv-
ing continuous Oi> by mask. The cord was not
clamped so that about 400cc of blood was lost.
Her clinical condition appeared to improve the
first two hours postpartum with considerable
resolution of the moist rales in the chest. Soon,
however, pulmonary edema again became evi-
dent with a marked sustained tachycardia.
Another phlebotomy for a total of 825 cc of
blood, adrenal steroids, positive pressure oxy-
genation, and digitalization produced no change
in the patient’s condition and she went into car-
dio-vascular collapse. The blood pressure was in
the range of 60 to 90 systolic and the pulse was
never less than 150. At 6:00 P.M. the patient be-
came comatose and expired three hours later.
Autopsy was obtained. Aside from pulmonary
edema, there was no additional anatomical diag-
nosis.
CASE NUMBER TWO:
This 38 year old gravida 4 para 2 was admit-
ted to McKennan Hospital from a nearby rural
community on 10/5/60. Fetal death had occurred
in late July and an attempt at induction in
August had failed. The patient had four pre-
vious term deliveries at this hospital. There was
no history of cardiac disease, but her physician
recalled an “hypotensive episode” immediately
following her past two labors. There was also a
history of delayed postpartum hemorrhage.
On admission the patient’s vital signs were:
Respiration 20, T. 99.6, Pulse 84 and Blood Pres-
sure 110/70. Dilation of the cervix was about 4
cm. The attending physician ruptured mem-
branes and, on the advice of a consultant, a slow
I.V. pitocin solution was started. The following
day there was little progress and scalp traction
on the fetal head was instituted. That evening
the patient developed a lower uterine constric-
tion ring at about 6 to 7 cm of cervical dilation
with the head high in the pelvis. On advice of a
second consultant, a version and extraction was
done under deep ether anesthesia without dif-
ficulty. During the anesthetic recovery period,
the patient developed a shock-like picture with
the blood pressure falling to 90 systolic and then
to 70/50 and her pulse increased from 90 to 130.
She was given lOOOcc of whole blood. A medical
consultant was called who began treatment for
acute heart failure with vasomotor collapse.
Despite transitory improvements in the pa-
tient’s blood pressure, a sinus tachycardia of 150
continued and the patient expired in acute pul-
monary edema eight hours following delivery.
Autopsy was obtained with the findings com-
patible with an acute cor pulmonale and a tis-
sue diagnosis of an isolated interstitial myocar-
ditis.
DISCUSSION
There appears to be a group of pregnant wo-
men who, during the last trimester or early
postpartum period, develop a fatal acute cardiac
disease which arises de novo inasmuch as there
is no known previous history of cardiac insuf-
ficiency. All the cases reported occurred in pa-
tients who were “old” from an obstetrical stand-
point, who were multiparous, and who had in
common no history of obstetrical complications
or cardiovascular disease in the past. Once acute
failure developed, the outcome was uniformly
fatal despite the most vigorous medical treat-
ment.
Despite the similarity of the clinical picture
there is no evidence that these deaths represent
a common etiological agent; only in the last case
was a postmortem diagnosis of a specific entity,
that of myocarditis, made. But even here the
internists have conflicting views on what con-
stitutes a non-specific myocarditis, and the lit-
erature on myocarditis in pregnancy is confus-
ing. A description of this syndrome under the
names of “isolated myocarditis,” Fiedler’s myo-
carditis, and “postpartal heart disease” reveals
some cases almost identical to the two cases des-
cribed above.
Acute myocardial infarction, pericarditis, and
multiple pulmonary emboli are a few of the
other common cardiac diseases which may term-
inate in an acute right heart failure during the
puerperial period. In the cases reviewed
above there was not sufficient good clinical or
postmortem evidence on which to base these
diagnostic possibilities.
Summary
The relative increase in the number of deaths
from cardiac disease in the puerperium should
alert the obstetrician to look for early signifi-
cant signs and symptoms in these patients des-
pite the lack of a history of previous insuffici-
ency.
(Continued on Page 30)
27
DEATH FROM RABIES IN A TEN YEAR OLD BOY
(One of two cases in United States
in 1966.)
G. Robert Bell, M.D.
De Smel, South Dakota
When his folks gave this patient a sleeping
bag for his tenth birthday, little did they know
that it would indirectly lead to his death. Four
days later he slept in a tent in a neighbor’s back
yard, in the town of Bryant, South Dakota. In
the early morning hours of August 3rd he was
awakened by a bite on the thigh. A skunk had
apparently crawled into the sleeping bag and
bitten him. In an attempt to get away the boy
was bitten severely on both hands, fingers, the
right wrist, neck, ear and abdomen. There were
only single bites on the ear, neck, abdomen and
thigh, but approximately fifteen to twenty bites
on the wrist, hands, and fingers of both hands.
Several had penetrated the nails and practical-
ly transversed the fingers in several places. The
bites on the wrist penetrated the tendons,
sheaths and several of the veins, causing consid-
erable subcutaneous hemorrhage.
The animal was finally beaten off with a base-
ball bat. An hour later, what was thought to be
the same animal was found several blocks away.
It was shot and the head taken to the Veterin-
ary Department at South Dakota State Univers-
ity at Brookings. A positive diagnosis of rabies
was made on direct smear, by finding negri
bodies in the brain of the skunk.1
INITIAL TREATMENT.
In the meantime, the local physician cleansed
the wounds with phisohex and water and paint-
ed them with tincture of merthiolate. A booster
tetanus toxoid was given also.
The patient was then taken to the closest hos-
pital, and seen by the author approximately
four hours after the attack. Considerable swell-
ing was present about the wrists, and pain was
present from subungual hematoma. High doses
of antibiotics were administered and a splint ap-
plied to the right wrist. Rabies antiserum and
vaccine were ordered immediately. According to
the Expert Committee on Rabies, World Health
Organization2, serum should be administered
in a single dose not less than 40 units per kg. of
body weight, followed by a full course of not
less than 14 vaccinations. Supplemental doses
may be given at ten and twenty days after
completing the series.
According to his weight of eighty pounds, 2000
units of antirabies vaccine was administered.
Approximately one-half was infiltrated into the
tissue surrounding the bites and the other half
injected intramuscularly. This was given within
fourteen hours of the bites. One hour later the
first Duck Embryo Vaccine was administered,
subcutaneously, in the abdominal wall. Because
of previous allergic manifestation and need of
mild sedation the boy was given Benedryl, 50
mgm q.i.d.
The hospital course was uneventful and the
patient was dismissed on the fifth day after ex-
posure. All wounds healed well and the boy was
seen daily for sixteen more days, receiving a
total of twenty-one shots of Duck Embryo Vac-
cine with nothing more than the usual local
redness and swelling.
PRODROMAL SYMPTOMS.
On August 27th, the 25th day after exposure
and four days after the last vaccine injection
the boy was seen as an out-patient, complaining
of fever, headache and stiff neck. The mother
then mentioned that he had remarked several
times during the past week about his right arm
going to sleep and then waking up.
Physical examination on admission revealed
only hyperactive reflexes of extremities and ab-
domen, and definite muscle rigidity of the neck.
The hospital course was a gradual worsening of
conditions. On the evening of admission he had
a temperature of 101°, was irritable and jumpy
with a poor sleeping pattern. The next day
brought fever of 102°, severe headache, blurring
of vision, twitching of nose, increased jumpi-
ness and hyperactive reflexes. On the 27th post-
exposure day a spinal tap was performed with
some elevated pressure and increase in lymph-
ocytes. There was more arm numbness and a
temperature of 104° which ASA wouldn’t con-
trol. Indocin was used with good success.
During the night and early morning of the
28
MAY 1967
28th day he developed hallucinations, wandered
into the hall, jumped straight up in bed, and
slept very little. The mental confusion was con-
siderable, but he could be talked into reality
by his mother. He frequently lapsed into a
semicoma. On the 29th day, after another bout
of 105° temperature, Indocin was again success-
fully used. The patient drank with difficulty,
aroused enough to complain of stiffness of arms
and legs, and mentioned that his throat hurt.
The face and lips were swollen and excessive
amounts of saliva and mucous collected in his
throat.
A neurologist was called. He suggested calling
the Eli Lilly Research Department, which was
done. They felt it sounded like rabies, but if it
were a vaccine reaction, then ACTH would be
of some help and still not suppress the immun-
ological response from the vaccine. Eighty units
of ACTH was given, as well as intravenous
fluids with no appreciable change.
TERMINAL STATE.
During the night and into the early morning
of the 30th day the patient developed hives and
did not respond to any stimuli. The extremities
became flaccid; respiration stopped while still
having a good pulse. A tracheotomy was per-
formed and IPPB was used from then until his
death. The patient was transferred ninety miles
by ambulance with IPPB, to the intensive care
unit of Sioux Valley Hospital.
The coma continued until death on Septem-
ber 5, thirty-four days after the attack, and only
thirteen days after the last dose of vaccine.
Because of the unusual nature of the case, ex-
tensive studies were performed after the boy’s
death. Cooperating in this very complete study
were Drs. Keith Sikes and Bob Warren of the
Rabies Control Unit, Veterinary Public Health
Unit, Atlanta, Ga.; Ben Diamond, Director of
State Laboratories at Pierre; Dr. Harshfield of
the Veterinary Science Department at SDSU,
Brookings, and James A. Rud, M.D., Pathologist
at Sioux Valley Hospital.
BLOOD AND TISSUE REPORTS.
On autopsy, tissues were submitted to State
Health and Communicable Disease Center Lab-
oratories for microscopic and virus isolation. Im-
pression smears from brain, lungs and salivary
glands were negative on direct fluorescent mi-
croscopic examination. Mice inoculated with the
brain suspension died of rabies within ten to
fourteen days after intracerebral inoculations.
The mouse brains were positive by fluorescent
antibody tests. No virus was isolated from the
salivary glands or lungs of the boy. When blood
was taken in the terminal stages, rabies serum
neutralizing antibody was present with a titer
greater than 1:50. It was the impression of the
Chief of the Rabies Control Unit, Dr. Sikes, that,
“The vaccine apparently successfully produces
the humeral antibodies, but the overwhelming
dose of virus was too great for the treatment to
be effective.”3
It has been the desire of all those involved
with this case to emphasize the importance of
rabies today. According to information made
available through a publication of the U. S.
Dept, of Health, Education and Welfare4 we
have had only one human rabies death a year
in the United States during the past three years.
However, since 1958 there were 23 deaths, three
have been in South Dakota. All were children
and all were bitten by skunks. At this writing
there have been two deaths this year in the
United States, the other was in Colorado.
EPIDEMIOLOGY
Rabid skunks have been a problem in South
Dakota since 1951. We had no skunks presented
for testing in 1950 although we had diagnosed
seven cases in other animals. Rabies was mov-
ing into North and South Dakota from Iowa
and Minnesota in 1950. Then in 1951 we accumu-
lated a total of fifty-six positive skunks. Every
year since 1951 skunks have led the list of the
different species in which rabies were found.
Table I5 is a compilation of information from
South Dakota records and from U. S. Public
Health records. It shows skunks have been at
the top of the list every year, and in all years
except 1965 they accounted for more cases of
rabies than all other animals added together.
From Table II4 we can see that the dog has
been decreasing in incidence (undoubtedly be-
cause of vaccination) but that bats, skunks and
foxes are increasing. Considering the fact that
rabid skunks have the highest viral content in
their saliva of any animal, it is not surprising
that skunks are thought to be the primary res-
ervoir of rabies because the transmission is so
deadly.
In the U. S. in 1965, 71% of the total rabies
cases were in wild animals. Skunks and foxes
accounted for 57% of all reported cases. Bats,
surprisingly, accounted for 10%. These figures
are primarily because of our large fox, skunk
and potential raccoon population. Some have
suggested that rabies is cyclic but according to
the Rabies Unit of Public Health4 “on a nation-
al basis there has been no observable cyclic
phenowave. Instead skunk rabies has increased
almost every year.”
— 29 —
SOUTH DAKOTA
Something more than present controls will
have to be used. States can be partially respon-
sible but the main control must be regional
programs by the Fish & Wildlife Service. Sev-
eral programs have been studied for Appalachia
and New England regions, and it would appear
one is needed now for the Midwest.
Summary
A case history of death from rabies in a ten year
old boy has been presented.
Reports from tissue studies and blood tests were
given, including comments from Chief of Rabies Con-
trol Unit, Atlanta, Georgia.
Tables are shown which give the relationship of
skunk rabies in South Dakota to that of other ani-
mals and the national statistics for the same.
Comments were made that in spite of an increas-
ing incidence of rabies there are no definite programs
of control at this time or planned in the future.
TABLE I.
LABORATORY DIAGNOSED RABIES
VETERINARY DEPT. S.D.S.U.
Species
1960
1961
1962
1963
1964
1965
1966*
Skunks
43
70
56
55
52
29
43
Cattle
16
23
29
25
16
19
12
Dogs
5
5
8
11
4
2
3
Cats
3
7
16
15
6
14
3
Others
6
2
5
2
1
5
4
(*9 months)
Information obtained from the Veterinary Dept, at
South Dakota State University.5
TABLE II.
INCIDENCE OF RABIES IN U. S.
BY TYPE OF ANIMAL
Year
Dogs
Cats
Farm
Animals
Foxes
Skunks
Bats
Other
Animals
Man
1953
5,688
538
1,118
1,033
319
8
119
14
1955
2,657
343
924
1,223
580
14
98
5
1957
1,758
382
714
1,021
775
31
115
6
1959
1,119
292
751
920
789
80
126
6
1961
594
217
482
614
1,254
186
120
3
1963
573
217
531
622
1,462
303
224
1
1965
412
289
625
1,038
1,582
484
153
1
Information obtained from U. S. Dept, of Health,
Education and Welfare. 4
REFERENCES
1. G. S. Harshfield, Head Veterinary Department. Per-
sonal communication. By phone and by letter dated
August 3, 1966.
2. World Health Organization Report Series.
Number 201; 1960
3. Dr. Keith Sikes, Chief Rabies Control Unit Com-
municable Disease Center, Lawrenceville, Ga.,
Personal communication.
4. Annual Rabies Summary, 1965. U. S. Dept, of
Health, Education and Welfare Public Health
Service.
5. G. S. Harshfield, Head Veterinary Dept., South
Dakota State University, Brookings, South Dakota.
Personal communication. September 28, 1966.
GENERAL PRACTITIONERS — Lennox,
South Dakota has exceptional opportunity
available for either single practice or part-
nership arrangement. Lennox Clinic build-
ing available; financial, professional ad-
vantages; splendid surroundings in South-
eastern South Dakota; large area to serve.
Ideal for becoming established. Inquiries,
visits welcome. Contact City Mayor Fred
Courey, chairman, medical services com-
mittee.
MATERNAL DEATH
(Continued from Page 27)
A history of progressive fatigue, dyspnea,
non-productive cough, and tachycardia occur-
ring in an elderly multipara should be enough
evidence to demand immediate attention of the
attending physician in order to rule out the pos-
sibility of early cardiac failure. Once estab-
lished, cardiac failure in these cases proceeded
to death despite adequate medical treatment.
REFERENCES
1. Abramson, J. and Tenny, B. Cardiac Disease In
Pregnancy. New England J. Med. 253: 279, 1955.
2. Ehrenfeld, E. N., Brzenenski, A., Braun, K., Sadow-
sky, E., and Sadowsky, A. Heart Disease In Preg-
nancy. Obst. & Gynec. 23: 363, 1964.
3. Gelfand, M. L. and Breindel, J. Acute Pericarditis
with Pulmonary Edema in Pregnancy. Obst. &
Gynec. 14: 803, 1959.
4. Mendelson, C. L. Acute Isolated Myocarditis. Am. J.
Obst. & Gynec. 61: 1341, 1951.
5. Piper, P. G., Kleppe, L. W. and Collins, J. D. Ma-
ternal Mortality: Report of Four Unusual Cases.
Am. J. Obst. & Gynec. 83: 328, 1962.
6. Phillips, O. C., Hulka, J. F., Vincent, M. and Chris-
ty, W. C. Obstetric Mortality: A 26 Year Survey.
Obst. & Gynec., 25: 217, 1965.
7. Report of Maternal Mortality Committee. Trends
of Maternal Mortality in South Dakota. S. D. Jour,
of Med. Vol. 19: 21, 1966.
8. Szekely, P. S., Snoith, L. Acute Pulmonary Edema
in Pregnancy. J. Obst. & Gynaec. Brit. Emp. 64:
840, 1957.
9. Walsh, J. J. and Burch, G. E. Postpartal Heart Dis-
ease. Arch. Int. Med. 108: 817, 1961.
30 —
S.D.J.O.M. MAY 1967 - ADV.
31
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ClINICOPATHOLOGICAl CONFERENCE - SIOUX VALLEY HOSPITAL
From the Intern and Resident Teaching Conferences of the Sioux Valley Hospital, Sioux Falls
John F. Barlow, M.D.*
Pat halo gist-Editor
Bernard J. Begley, M.D., F.A.C.S.**
Urologist-Discusser
This 63-year old Caucasian female developed
pain in the right upper abdominal area 10 days
prior to admission. The pain was dull, aching,
and nonradiating. She was admitted to another
hospital. She had lost some strength lately but
had not noticed change in urine color, fre-
quency, urgency or change in bowel habits. The
remainder of the history was unremarkable.
Physical examination revealed a pale lady
with pulse rate of 84, blood pressure 158/88, res-
pirations of 20, and temperature 101°. The only
positive physical finding was a large, slightly
tender moveable mass in the right flank which
could also be felt in the right upper quadrant.
The examiner felt the mass was renal. Flat
films of the abdomen showed a soft tissue mass
in the renal region with a radiolucent center.
Intravenous pyelogram showed a mass in the
lower pole of the right kidney. The mass had a
large radiolucent center and was 12 x 14 cm.
No calcifications were seen. The kidneys func-
tioned normally. The chest and colon were nor-
mal by x-ray.
The urinalysis revealed straw-colored urine
with specific gravity of 1.017, pH 6.0, no glucose,
protein, or hemoglobin. The sediment showed
0-2 wbc/hpf and an occasional RBC. Admitting
hemoglobin was 8.9 gm%, red count 2,820,000
1mm3, hematocrit 28%, mean corpuscular he-
moglobin 32 micro micrograms, mean corpuscu-
lar volume 100 cubic micra and mean corpuscu-
lar hemoglobin concentration 32%. The white
count was 10,700 1mm3 with 74% polys, 3%
bands, 3% eosinophils, 18% lymphocytes, 2%
monocytes. The red cells were normachromic
and normocytic. The platelets were adequate.
Erythrocyte sedimentation rate was 108 mm/hr.
Blood urea nitrogen was 15 mg%. she was trans-
fused with two units of blood and an operation
was performed on the third hospital day.
* Lecturer in Pathology, School of Medicine, Univ.
of S. Dak.
** Assistant Professor of Urology, School of Medi-
cine, Univ. of S. Dak.
Urologist - Sioux Valley Hospital
CLINICAL DISCUSSION
Dr. Bernard J. Begley: In summary, the pa-
tient is a 63-year old lady with noncolicky ab-
dominal pain, an abdominal mass of short dura-
tion, fever, and an intravenous pyelogram re-
vealing a mass in the lower pole of the right
kidney with the unusual finding of a radiolu-
cent center. Positive laboratory findings include
anemia of rather marked degree and marked el-
evation of the erythrocyte sedimentation rate.
May we see the x-rays?
Dr. Donald H. Breil*: There is no abnormal-
ity of the heart or lungs on the chest film. There
is no evidence of rib metastases. Next are flat
films of the abdomen in which you can see a
good-sized mass with a rather large radiolucent
area (fig. I). This radiolucency can be due to
Fig. I - Note radiolucent mass with radioopaque per-
iphery.
only two things, air or fat tissue. From the flat
film one wonders if this might not represent a
dilated segment of colon filled with air. This is
probably why a barium enema was done. The
colon is nicely outlined and the mass is clearly
above it. This means that the next step was an
intravenous pyelogram. You can see now that
the mass takes origin from the kidney and forms
* Radiologist - Sioux Valley Hospital
32
MAY 1967
a large ovoid tumor with a radiolucent center.
The nonepithelial tumors of the kidney come
from connective tissue, adipose tissue, muscle,
blood vessels or lymphatics. This particular tu-
mor appears to be a fatty tumor of some type.
Hamartoma is a term that has been used in the
literature for such a tumor. Of course, we radi-
ologists cannot differentiate between liposar-
coma and benign lipomatous tumor. The tumor
caused sudden pain in the right upper quadrant.
Hamartomas may call attention to themselves
when pain is produced secondary to hemorr-
hage or infarction.
Dr. Begley: I was impressed on the x-rays
that there are two components to the tumor. I
see an outer rim of opaque tissue and a radiolu-
cent center which is accentuated because of the
outer rim. Many renal hamartomas or angiomy-
olipomas are mixed tumors and we may be see-
ing the separate tissue components on the x-ray.
Whenever the clinician encounters a renal
mass, three separate types should be considered:
the neoplastic renal mass, benign and malig-
nant; the inflammatory renal mass which is cer-
tainly the most common one; and the cystic re-
nal mass which is quite common. The inflam-
matory renal mass would be a good one for the
pathologist to present if this were going to be
written up in the State Journal. I believe I can
exclude a parasitic cystic mass since there is
no history of the patient being out of the coun-
try and the history is of short duration. A cyst
of the kidney would not generally produce this
sedimentation rate elevation unless it is an ad-
enocarcinoma with cystic degeneration or a
cystadenocarcinoma. We are left with the solid
masses of the kidney. Certainly there is some-
thing of much less density in the main core of
the mass. We must consider the connective tis-
sue tumors — the lipomas and angiomyolipomas
or the so-called hamartomas which generally
have associated new blood vessel formation.
Actually, they derive their name in part from
their vascularity.
With many renal masses we have little or no
correlative laboratory information but the an-
emia and elevated sedimentation rate here raise
the suspicion that we are dealing with a condi-
tion not as benign as the symmetry of the mass
and the fat would lead us to believe. In general,
most renal masses require exploration — there
are only a few in which one can dare omit sur-
gery. These are in elderly people when one feels
strongly from the shape of the mass that it rep-
resents a renal cyst. If it is large enough and
one is fortunate enough, he may be able to in-
sert a spinal needle into the cyst and aspirate
clear fluid. He might then inject the mass with
contrast media and demonstrate no extra filling
defects within the cystic mass. After all this,
he could probably safely temporize. Otherwise
renal masses require surgical exploration.
The adenocarcinoma or so-called hyperneph-
roma constitutes 95% of the solid tumors of the
kidney. If one feels that he is going to encounter
such a malignant tumor, I personally feel the
only way one can satisfactorily ligate the ped-
icle without too much manipulation of the kid-
ney is through the thoraco-abdominal approach
popularized by Dr. Chute many years ago. The
most common method is through a conventional
flank approach. However, I think that with a
large mass and the possibility of renal carcin-
oma the thoraco-abdominal approach allows the
earliest ligation of the renal pedicle.
Dr. John F. Barlow: Are there other com-
ments?
Dr. Barry Piil-Hari*: How certain are you
that this is a primary renal tumor and not a
lower retroperitoneal tumor encroaching upon
the kidney?
Dr. Begley: This type of distortion of the low-
er collecting system should not occur from a
retroperitoneal tumor. If this were an extra-
renal tumor in the retroperitoneum then the en-
tire renal axis should be shifted. The lower
calyx itself would definitely be affected and
should be displaced along with the kidney
rather than being independently distorted.
Dr. Dorence L. Ensberg**: Would a lateral
film be of value here?
Dr. Begley: I don’t think so. In a patient of
this age I would be suspicious of malignancy
from the films despite the radiolucency. The in-
creased sedimentation rate with anemia and
fever are almost pathognomonic of a malignant
tumor of the kidney. If this lady had had a more
prolonged course, one might consider a renal
carbuncle forming a fistula into the second por-
tion of the duodenum or ascending colon which
lie in rather intimate contact with the right
kidney. This has been reported a number of
times.
Dr. Adrian Wolbrink***: Could the mass be
traumatic in origin?
Dr. Begley: There is certainly no history of
trauma. This lady just developed a dull pain. I
* Chief Resident in Pathology, Sioux Valley Hos-
pital
** Surgeon, Sioux Valley Hospital. Associate Pro-
fessor of Surgery, School of Medicine, University
of South Dakota
*** Intern, Sioux Valley Hospital
33 —
SOUTH DAKOTA
have made a point to look in some textbooks of
urological radiology and was not able to find a
case with this degree of radiolucency in a lipo-
matous tumor. I have seen hamartomas and an-
giomyolipomas with a fair amount of fat in them
but not with this much radiolucency. I wonder
if this is a rim of hemorrhage about the tumor
accentuating the radiolucency.
These hamartomas are oddities and many do
not have hemorrhage into them. The sedimenta-
tion rate is markedly elevated. This is one of the
important criteria for carcinoma of the kidney.
If it were normal you could be reasonably cer-
tain that the mass would not be a carcinoma and
would probably be cystic. The sedimentation
rate coupled with the fact that carcinoma of the
kidney occurs in the fourth, fifth, and sixth dec-
ades strongly points to carcinoma.
Dr. Ensberg: Do you really feel that the pa-
tient bled into her tumor enough to lower her
hemoglobin to 8.9 gms% or is there another
mechanism for the anemia?
Dr. Begley: There are a number of blood dis-
turbances with renal carcinoma. Generally
speaking the anemia is usually on the basis of
blood loss. There may be tremendous hemorr-
hage into a renal tumor. I have seen large renal
cell carcinomas two-thirds replaced by hem-
orrhage.
It has also been estimated that 1-2% of renal
tumors (I don’t personally feel it is that high)
have red cell hyperplasia or secondary poly-
cythemia with hemoglobins of 17 or 17 grams %.
This is caused by erythropoietin which is sup-
posedly elaborated by the kidney tumor. How-
ever, the anemia in renal neoplasms is frequent-
ly due to hemorrhage either into the tumor or
out through the urinary tract.
Dr. Ensberg: I feel in this case the amount of
hemorrhage very well may not explain the
anemia.
Dr. Begley: This lady may have been mildly
anemic to start.
Dr. Barlow: Some patients with renal angio-
lipomas may even present in shock due to hem-
orrhage.
Dr. Ensberg: In this patient though, I feel
there is not enough blood loss to explain such
severe anemia. I am just trying to keep the dis-
cussion honest (laughter).
Dr. Duane L. Greenfield*: This lady had a
massive perirenal hemorrhage. In fact, she her-
self first felt the mass shortly after she had the
* Urologist, Sioux Valley Hospital, Assistant Profes-
sor of Urology, Medical School, University of South
Dakota
pain. The size of the mass was undoubtedly in
large part due to hemorrhage.
Dr. Begley: I also believe the pain was prob-
ably due to hemorrhage. I have seen tumors
larger than this that the patient was not aware
of until he had pain and a physical examination
was performed. I think we find more small kid-
ney tumors today with the increased use of in-
travenous pyelography. In some institutions 20-
25% of renal tumors are “incidental” findings
on x-rays done in a complete workup.
Dr. Bernard Begley's Diagnoses
1. Renal Angiomyolipoma (Hamartoma)
2. ? Renal Cell Carcinoma (Hypernephroma)
PATHOLOGICAL DISCUSSION
Dr. John Barlow: The surgical specimen was
a hemorrhagic 772 gram mass measuring 19 x 12
x 9 cm. The major portion consisted of bright
yellow adipose tissue with a rim of hemorrhage
(Fig. 2). On microscopic section the tumor was
Fig. II
The kidney is at the lower portion of the picture. The
tumor (corresponding to the X-ray shadow) is filled
with fat and outlined by hemorrhage.
composed predominantly of adipose tissue with
clusters of blood vessels and areas of spindle
cells with slightly atypical, hyperchromatic
nuclei. There was marked necrosis and hemorr-
hage around the tumor (Fig. 3). The latter
explain the abdominal pain and anemia. The
34 —
MAY 1 967
Fig. III. - Note adipose tissue, vessels and spindle
cells representing components of angio-
myolipoma on right and necrosis and
hemorrhage on left.
mixture of elements histologically is diagnos-
tic of an angiomyolipoma or renal hamartoma.
Angiomyolipomas are rare and frequently
are seen in tuberous sclerosis. In this condition,
the angiomyolipomas are often multiple and bi-
lateral. However, large angiomyolipomas do oc-
cur in the absence of tuberous sclerosis.
Angiomyolipomas often present with pain or
anemia secondary to hemorrhage or infarction
within the tumor. An excellent review of these
lesions was written by Price and Mostofi.1 They
reviewed 30 cases, 21 of which were females and
9 males showing a definite female predomin-
ance. The average age was 40 years but they
ranged from 12 to 69 years.
The authors divided the patients into three
groups according to their symptoms: Group I
had sudden onset of pain or shock due to hem-
orrhage. There was usually a palpable mass.
Group II had abdominal pain and hematuria
with symptoms lasting from two weeks to ten
years. Group III had fever and pain and indef-
inite symptoms.
Pathologically the lesions were composed of
varying proportions of smooth muscle, blood
vessels and adipose tissue. Hemorrhage and ne-
crosis were frequent. The varying proportions
of tissue explained a gross picture ranging from
a solid tumor to a hemorrhagic or fatty mass.
X-ray examination, as was shown in this case,
may be very helpful. Important points brought
out by the authors were that the smooth muscle
component may show hyperchromatic cells
which vary in size and shape. Also venous in-
vasion may be seen. In spite of this the lesions
are clinically benign. None of the 30 patients
died from angiomyolipoma.
FINAL DIAGNOSIS
1. Angiomyolipcma with Hemorrhage and
Necrosis.
BIBLIOGRAPHY
1. Price, Edward B., Mostofi, F. K., “Symptomatic
Angiomyolipoma of the Kidney,” Cancer, June,
1965, pp. 761-774.
2. Keshin, Jesse, “Three Cases of Renal Hamartoma:
Two Presenting with Spontaneous Rupture and
Massive Retroperitoneal Hemorrhage,” Journal of
Urology, October, 1965.
3. Allen, Terry D., and Risk, William, “Renal Angi-
omyolipoma,” Journal of Urology, September, 1965.
4. Chute, R., Soutter, L. and Kerr, W. S., Jr., “Value
of Thoraco-Abdominal Incision in Removal of Kid-
ney Tumors,” New England Journal of Medicine,
241:951-960, 1949.
5. Chute, R. and Soutter, L., “Thoraco-Abdominal
Nephrectomy for Large Kidney Tumors,” Journal
of Urology, 61:688-696, 1949.
6. Chute, Richard, “The Thoraco-Abdominal Incision
in Urological Surgery,” Journal of Urology, 65:
784-794, 1951.
7. Jones, G. H., Melendy, O. A., and Flynn, W. F.
“Spontaneous Nephroduodenal Fistula: Review of
Literature and Report of Case,” Journal of Urol-
ogy, 69:760-763, June, 1953.
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— 35 —
SOUTH DAKOTA
MINUTES OF THE COUNCIL MEETING
Sunday, April 2, 1967 Ramada Inn
11:00 a. m. Sioux Falls, S. D.
The meeting was called to order at 11:00 a. m. by
E. T. Lietzke, M.D., Chairman of the Council. Present
for roll call were Drs. P. Preston Brogdon, J. J.
Stransky, J. T. Elston, A. P. Reding, R. H. Quinn, E. J.
Perry, James P. Steele, Paul Hohm, G. Robert Bar-
tron, J. A. Muggly, A. J. Tieszen, Fred Leigh, Harvard
Lewis, Clark Johnson, John Gregg, George Knabe
and D. L. Scheller. Also present were R. H. Hayes,
M.D. and Mr. Richard C. Erickson. Dr. Reding moved
to dispense with the reading of the minutes inasmuch
as they have been mailed to all Councilors. The mo-
tion was seconded and carried.
Dr. John B. Gregg reported on activities of the
Commission on Medical Service.
REPORT OF THE COMMISSION ON MEDICAL
SERVICE TO THE COUNCIL OF THE SOUTH
DAKOTA STATE MEDICAL ASSOCIATION
PREPARED FOR ITS MEETING APRIL 2, 1967
As of the date of preparation of this report there
has been no formal meeting of this commission. There
will be a meeting of the commission and the Medical
School Endowment Committee at the Medical School
in Vermillion on Saturday, March 18, 1967. However,
this meeting will be too late for a report to be pre-
pared for the Council meeting. If any important in-
formation is forthcoming from the Commission meet-
ing, it will be reported verbally to the Council.
In the interval since the last Council meeting the
following matters of business have been undertaken
by this commission:
(1) Traffic safety — No report.
(2) Immunization - School Health — A letter has
gone to each physician in the State of South Dakota
relating to the availability of the Phillips Roxanne
type measles vaccine now available through the Vac-
cination Aid Program at Pierre.
(3) Rural Health — No new report. A meeting is to
be attended in Chapel Hill, North Carolina, by Dr.
J. A. Anderson of Madison in the very near future,
on the subject of rural health. A report to the Council
will be forthcoming when available.
(4) Nurse training — A copy of the report concern-
ing the meeting of the South Dakota Planning Coun-
cil for Nursing Resources, attended by Dr. G. F.
Tuohy is attached herewith.
(5) Hospital Utilization - Insurance advisory — No
report.
(6) Medical School Affairs - Medical education — A
meeting of the Third Annual Meeting of the Chair-
men of State Medical Society Committee on Medical
Education and Hospitals was attended by Doctors
George Knabe and J. W. Donahoe. Their reports are
attached herewith. The report of the meeting of the
Medical School Affairs Committee in Vermillion as
noted above will be reported later.
(7) The First National Congress on the Socio-Econ-
omics of Health Care, held in Chicago January 22
and 23, 1967, was attended by J. B. Gregg, M.D. A
report of this meeting is attached herewith. An edi-
torial for the editorial page of the Journal of the
South Dakota State Medical Association has been pre-
pared and submitted directing the attention of the
physicians in this state to the subject and inviting
their perusal of this matter as reports appear in the
J.A.M.A. and other periodicals.
(8) The meetings of the Heart-Cancer-Stroke Plan-
ning Committee have been attended by J. B. Gregg,
M.D. as a representative of the Commission on Medi-
cal Service. In the capacity of acting secretary for
this planning group, minutes of the committee meet-
ings have been compiled and are available to inter-
ested parties upon request.
Respectfully submitted,
John B. Gregg, M.D., Chairman
A REPORT ON THE MEETING OF THE SOUTH
DAKOTA PLANNING COUNCIL FOR
NURSING RESOURCES
A follow-up meeting was held on December 21,
1966 at the College of Nursing, South Dakota State
University.
Miss Helen Foerest, U. S. Public Health Service, re-
ported to the members of her activities the past sev-
eral weeks in South Dakota. She has been gathering
general data regarding care, private duty nursing,
office nursing and other materials by personal inter-
view around the state of South Dakota.
Information is still not readily available in this
regard and employment incentives, utilization of
nurses in rural hospitals and attrition rate in college
nursing programs is yet to be investigated.
She will meet with the president of the Medical
Assistants in Chicago on February 3, 1967 to get clari-
fication of their role in the health field.
The South Dakota Hospital Association and other
groups have offered to cooperate in securing infor-
mation needed for the preliminary report. In the
area of nursing education, an enrollment survey may
be necessary as well as information on the cost of
nursing educations to the student and to the school.
Educational preparation of faculty and budgeted va-
cancies of faculty could be included in the survey.
Public Law 89-749 provides monies to states for
comprehensive health planning. South Dakota has
been appropriated $25,000 for the fiscal year ending
July 1967. The second appropriation will be $50,000
July ’67-’68. At this time no guide lines have been
established for Public Law 89-749 and no action can
be taken until these are published.
The name of Miss Evelyn Peterson was brought for-
ward for director of the study project and she will
be contacted in this regard. Sources of private funds
were suggested and discussed. The chairman of this
group will appoint a group to list organizations for
financial sources and also to write Governor Boe to
give him a progress report of this committee and ad-
vise him of the law and our need for financial sup-
port.
No date was set for the next meeting.
Respectfully submitted,
G. F. Tuohy, M.D.
REPORT OF THE THIRD ANNUAL MEETING OF
CHAIRMEN OF STATE MEDICAL SOCIETY
COMMITTEES ON MEDICAL EDUCATION
AND HOSPITALS
Convened by the A.M.A. Council on Medical
Education at the 63rd Annual Congress on
Medical Education, Chicago, February 11,
i967.
Representatives of State medical societies, specialty
boards and other groups concerned with medical ed-
ucation were present. W. Clarke Wescoe, M.D., Chair-
man of the Council on Medical Education, introduced
the subject, the Millis Report, and indicated six areas
for discussion: 1. the corporate responsibility for med-
ical education, 2. the future of the internship as a
separate year of training, 3. experiments in medical
education, 4. the status of institutional accreditation,
5. the proposed new commission to supervise gradu-
ate medical education, and 6. the establishment of a
new specialist, the “primary physician.”
Most conceded the study was needed. However, a
lack of spontaneous and prepared comment on the
Report was interpreted by some as an indication that
many considered present systems of supervision and
improvement of medical education and practice to
be operating satisfactorily. “What’s the problem?”
said one doctor. The Citizens’ Commission on Gradu-
ate Medical Education apparently was unable to un-
derstand how the various facets of medical training
were controlled inasmuch as undergraduate educa-
tion is under supervision of medical schools, intern-
ships are under hospitals and residencies under spe-
cialty boards. Therefore, the Millis Report recom-
mended a “Commission on Graduate Medical Edu-
cation be established specifically for the purpose of
planning, coordinating, and periodically reviewing
standards for medical education and procedures for
reviewing and approving the institutions in which
36 —
MAY 1967
that education is offered.” Most in attendance dis-
agreed with the proposed composition of this super-
body, feeling that established groups within medi-
cine, such as the Council on Medical Education of the
A.M.A., the Joint Commission on Accreditation of
Hospitals, the Association of American Medical Col-
leges and the Advisory Board of Medical Specialties
could better coordinate to serve this purpose.
The medical specialty boards were applauded as
having made significant contributions to medical pro-
gress. The American Academy of General Prac-
tice indicated appreciation of their efforts and hopes
there will be a new specialty with the creation of
the “Family Physician,” a new category of doctor
different from the general practitioner of old.
The Millis Report’s recommendation to abolish the
internship and incorporate this into the medical cur-
riculum was viewed with alarm. It was indicated
that this would cause problems for the Boards and
that they would probably oppose it. Some agreed
that educational deficiencies of internship programs
were often a result of hospital boards of trustees lack-
ing the “corporate responsibility” to spend money
on education.
It was noted that various recent reported studies
have documented that a true public need has been
demonstrated for family physicians. Medical school
emphasis on the specialty approach has contributed
to decline in medical student interest in this field. If
organized medicine does not meet the need, legisla-
tive political action will determine how medicine
will be taught and practiced.
George W. Knabe, Jr., M.D.
Acting Dean, School of Medicine
REPORT OF THE MEETINGS OF THE A.M.A.
COUNCIL ON MEDICAL EDUCATION AT THE
63rd ANNUAL CONGRESS ON MEDICAL
EDUCATION, CHICAGO, FEBRUARY, 1967
The Medical Education Committee meetings were
so involved and contained so much revolutionary
material that it would take much time to elaborate.
In essence, the following points were covered in de-
tail:
(1) Dr. Millis gave a 45 minute paper discussing in
detail various facets of his original report which is
available to all who are interested. It is suggested
that this be read carefully. His family practice in-
ternship was discussed as was the marked and rapid
changes that are taking place in the medical schools
themselves, EG., gearing the fourth year toward the
eventual field the budding M.D. will take (orthope-
dics, urology, etc.)
(2) Heart, stroke and cancer regional centers will
do more to change the face of medicine than any
other situation.
(3) The feeling that medical education beyond for-
mal medical school education will be brought back
to the medical schools and the community hospitals
will play a secondary or helping role in this process.
EG., The community hospital will probably be af-
filiated with a medical center or a four year school
as the second year in a three year residency.
(4) Even state board examinations will have to
change. The candidate’s reasoning ability and judge-
ment will have to in some way be tested. A re-exam-
ination schedule for all licensed physicians as in
driver testing. CAA examinations, etc., may be in
the future, EG., Some type of re-examination every
five years.
From the two days of lectures and discussions I
heard, I felt more and more that South Dakota must
have a four year medical school. I further felt that
many more physicians than now do so, must involve
themselves in the medical education, administration
and medical politics fields or we in South Dakota will
be left behind and will be mere minor satellites to
our neighboring states. (Sioux Falls is the largest city
in a five state area and we need not assume a minor
role.)
Respectfully submitted,
John W. Donahoe, M.D.
A REPORT OF THE FIRST NATIONAL CONGRESS
ON THE SOCIO-ECONOMICS OF HEALTH CARE
HELD IN CHICAGO JANUARY 22, 23, 1967
The South Dakota Medical Association was well
represented at this meeting by Doctors P. Brogdon,
R. Brown, R. Leander, A. Reding and J. Gregg.
This was a very interesting and informative meet-
ing and. one which the physicians of South Dakota
are going to have to take interest in and note of
insofar as the future development of medicine in this
state and in the United States. One gained the im-
pression while listening to the various discussions
that the social reformers are now in the driver’s seat
and intend to press their advantage in the develop-
ment of medicine in this country in the future.
The meeting was broken into four sessions: (1)
orientation and overview, (2) the hospital and its
changing role in health care, (3) Mobilizing health
manpower, (4) financing of health care services.
During the first session it was emphasized that
there is a need to survey the health care in this
country, develop health statistics and make these
available in an impartial fashion for common usage
so that better programs for treatment can be devel-
oped. One of the more interesting discussions during
this program emanated from the University of Okla-
homa. This state is now developing a program to sur-
vey the health needs in that state, mobilize the medi-
cal and paramedical manpower with the University
of Oklahoma as the nucleus and then develop a pat-
tern of health care throughout the state.
The second session included some thoughts which
the hospital staffs in this state should be aware of.
These included the development of the concept that
the hospital is a single organization, not separate
medical staffs and administrations. The governing
board is ultimately responsible for all that takes place
in the hospital and has a vital interest in the pro-
fessional standards and the quality of patient care.
The medical staff must conscientiously and system-
atically review the medical practice in the hospital.
The appointment of full time salaried medical dir-
ectors in hospitals and possibly full time chiefs of
major services was also discussed. Up to date bylaws
are most important.
Means to assess the quality and patient care in the
hospital were discussed with the recommendation
that the hospital staffs are going to have to develop
techniques to standardize and improve the care of
the patients. The subject of emergency care in the
community and emergency room care was discussed.
It was recommended that emergency room service be
made available by one hospital in the community and
that a program of education of the community to this
fact be carried on. This would save duplication of
equipment and personnel and would promote better
quality emergency care. Disaster type medical care
for communities must be developed and rehearsed.
The third session contained discussion in regard to
the training of medical and paramedical personnel.
Much of the training of paramedical personnel could
be carried out in community colleges. Graded sys-
tems of responsibility and training for specific areas
of endeavor were encouraged. The development of
a program of assistant physicians to be utilized in
small communities where physicians may not be
available was also considered. The discussion of the
community health center program of the State of
Oklahoma was presented. Under this program the
practitioners in the state are members of the teach-
ing staff of the University; go to the University to
teach and to be taught on a regular basis. Graduated
medical care with the more difficult cases being
treated at the University’s Hospitals in Oklahoma
cities was advocated. Much of the plan envisioned
for Oklahoma could be made applicable to the State
of South Dakota. The development of health centers
for urban areas was also discussed. The requirements
of the military for manpower in the medical and
paramedical field was discussed.
The fourth session involved presentations relating
to cost and financing of health care service. One of
the more interesting discussions was presented by
Wallace S. Sayre, Professor and Chairman Depart-
37-
SOUTH DAKOTA
ment of Public Law and Government, Columbia Uni-
versity. Dr. Sayre pointed out that whether the medi-
cal profession likes it or not they are now in the
realm of politics and they are going to have to learn
the rules of politics rapidly. One of the fundamentals
which he stressed was that of bargaining in order to
accomplish the goals which may be desired. In the
development of health care programs under the ex-
isting law of the land the medical profession as a
whole and individually are going to have to face
the political facts of life. One of the discussions dur-
ing this session, the impact of Titles 18 & 19 P. L.
89-97 was rather eagerly awaited by those in attend-
ance at this meeting. However, the discussor, Walter
J. McNerney, President, Blue Cross Association, did
not shed much light on the problem other than to
indicate that there had been too short a time since
these programs went into action to form any definite
conclusion.
At a later date this program will be published for
general consumption. It is strongly recommended
that each physician in the State of South Dakota
read this material carefully because it is the opinion
of this observer that the patterns which were sug-
gested in Chicago are going to come to pass sooner
or later.
John B. Gregg, M.D., Chairman
Commission on Medical Service
A discussion was held on the Comprehensive
Health Planning Committee and an ad hoc committee
of three men from the Council was set up to study
this plan. Dr. E. J. Perry moved that R. H. Hayes,
M.D., G. Robert Bartron, M.D. and Fred Leigh, M.D.
form the ad hoc committee on Comprehensive Health
Planning. The motion was seconded and passed unan-
imously.
A discussion was held on the measles vaccine pro-
gram. Dr. Fred Leigh moved that the Medical As-
sociation encourage the program but leave imple-
mentation at the district level. The motion was sec-
onded and passed unanimously.
Dr. P. Preston Brogdon discussed a request re-
ceived from the State Board of Nursing asking the
approval of the Association for the use of films on
closed cardiac massage and resuscitation in training
nurses. Dr. Brogdon moved that he be authorized to
write a letter stating that the use of films on closed
cardiac massage and resuscitation are proper in the
nurses training program. The motion was seconded
and passed unanimously. Dr. J. T. Elston moved that
the report of the Commission on Medical Service be
accepted. The motion was seconded and passed unan-
imously.
REPORT OF THE COMMISSION ON LEGISLATION
AND GOVERNMENTAL AFFAIRS
More bills appeared before the 1967 Legislature
than expected in regards to health problems. A
bill requiring all motorcycle operators and pas-
sengers to wear protective head gear passed. Phar-
macy licensing bill passed with the amendments sug-
gested by the Medical Association. Bill providing
authorization for cities and counties to provide am-
bulance service was passed. Reporting of gun shot
wounds was passed. House bill #613 to establish Medi-
care Analysis Corporation was killed. Senator Bar-
tron’s bill for financial assistance (matching funds)
totaling $460,000 passed both houses. This was vetoed
by the Governor and then was passed over his veto.
Senate bill #145 to license hearing aid dealers was
killed in committee. Bill #219 amending the podiatry
law passed with the amendment proposed by the
Medical Association.
Representative E. Y. Berry is proposing national
legislation to control Medicare Title XIX. His pro-
posals are good for the State of South Dakota. The
proposals that he introduced would allow the state
more leeway and more time in implementing Title
XIX without national governmental penalties. (HR-
5710).
A luncheon for the legislators in Pierre was held
by the South Dakota Medical Association.
Dr. R. J. Foley of our commission attended the
Emergency Health Service committee in Sioux Falls
on February 7, 1967. This meeting was held to plan
a seminar to be held in the spring of 1967 on disas-
ter planning. This meeting will be held on April 13,
1967 and Doctor Foley plans to attend this meeting.
He is also attending the AMA Emergency Medical
Services conference in Chicago this spring.
The planned informal meeting of the commission
to be held in February at Pierre was canceled due
to inclement weather.
A meeting of the commission will be held at the
time of the annual meeting in Rapid City.
Respectfully submitted,
Robert H. Quinn, M.D., Chairman
Commission on Legislation and
Governmental Affairs
Mr. Erickson summarized the bills concerning the
Medical Association for the report of the Commission
on Legislation and Governmental Relations. Dr. E. J.
Perry moved that a vote of thanks be extended to
G. Robert Bartron, M.D. for his work in the State
Legislature. The motion was seconded and passed
unanimously.
Mr. Erickson discussed a letter received from Sen-
ator McGovern requesting the Association’s opinion
of a bill granting loans for small medical groups to
set up clinics. The Council directed Mr. Erickson to
write Senator McGovern stating the Medical Associ-
ation’s position on the proposed bill. Dr. E. J. Perry
moved that the report of the Commission on Legis-
lation and Governmental Relations be accepted. The
motion was seconded and passed unanimously.
Dr. George Knabe reported on the activities of the
Commission on Scientific Medicine. He discussed the
progress of the new building for the Medical School.
A discussion was held on the TB program and Dr.
Elston outlined the program being used in the Black
Hills District.
Dr. Brogdon moved to accept the report of the
Commission on Scientific Medicine. The motion was
seconded and passed unanimously.
Dr. D. L. Scheller gave a report on the Commission
on Internal Affairs. A brief discussion was held on
the resolution of the Pierre District Society to move
the Medical Association headquarters to Pierre. Dr.
G. R. Bartron moved that the headquarters not be
moved to Pierre. The motion was seconded and
passed. Vote: 16 for, 1 against. Dr. Perry moved that
the Council accept the report of the Commission on
Internal Affairs. The motion was seconded and passed
unanimously.
Mr. Erickson reported for the Commission on Com-
munications. A brief discussion was held on plans for
a booth at the State Fair. No action taken. Mr. Erick-
son also announced the promotion of Robert Johnson
as Director of Public Relations for the Association
and Blue Shield. Dr. Reding moved to accept the
report of the Commission on Communications. The
motion was seconded and passed unanimously.
Mr. Erickson reported for the Commission on Liai-
son with Allied Organizations and briefly discussed
the pharmacy bill. Dr. Brogdon moved that the report
of the Commission on Liaison with Allied Organiza-
tions be accepted. The motion was seconded and
passed unanimously.
OLD BUSINESS
To fill the term ending June 30, 1967 on the Board
of Medical and Osteopathic Examiners, Dr. James
Steele moved that the names of Dr. R. A. Buchanan.
Dr. J. T. Elston and Dr. George Knabe be submitted
to the Governor. The motion was seconded and passed
unanimously.
The nomination of M. Stuart Grove, M.D. for life
membership in the Association from the Seventh
District Medical Society was presented to the Coun-
cil. Dr. Reding moved that Dr. Grove be accepted as
a life member. The motion was seconded and passed
unanimously.
(Continued on Page 47)
38 —
MAY 1967
(Continued from Page 38)
Dr. Russell Brown discussed the full payment con-
tract which has been prepared by South Dakota Blue
Shield. He also suggested that the Commission on
Medical Service review the standard claim form
developed by the AMA and the Health Insurance
Council. Dr. Bartron moved that the Commission on
Medical Service study the claim form and return a
recommendation to the Council. The motion was sec-
onded and passed unanimously.
A discussion was held on a permanent representa-
tive to the Heart, Cancer and Stroke Executive Com-
mittee. Dr. Reding moved that Dr. Paul Hohm repre-
sent the Medical Association at the Heart, Cancer and
Stroke Committee and that the president of the State
Association act as an ex officio member. The motion
was seconded and passed unanimously.
Dr. E. J. Perry moved that Richard C. Erickson be
named as registered agent of the Medical Associa-
tion. The motion was seconded and passed unani-
mously.
Mr. Erickson held a brief discussion on the agenda
of the annual meeting.
Dr. J. T. Elston discussed a bill set up to regulate
medical laboratories. The South Dakota Pathology
Society will draft a bill and submit it to the Com-
mission on Legislation and Governmental Relations.
Dr. John Gregg discussed a bill to license hearing
aid dealers. It was decided that recommendations
should be made to the Commission on Legislation
and Governmental Relations concerning such a bill.
Dr. Reding discussed the group disability plan
through the American Medical Association. No action
taken.
The meeting adjourned at 3:00 p. m.
MEETING OF THE COMMISSION ON
MEDICAL SERVICE
March 18, 1967
Vermillion, South Dakota
The meeting convened at 1:00 p.m. The members
present for roll call included J. B. Gregg, M.D.; H. P.
Adams, M.D.; T. H. Willcockson, M.D.; G. E. Tracy,
M.D.; and Warren Jones, M.D. Also in attendance
were P. P. Brogdon, M.D.; R. H. Hayes, M.D.; George
Knabe, Jr., M.D.; E. T. Lietzke, M.D.; and Mr. Rich-
ard C. Erickson.
A discussion of the state immunization was held.
Dr. Tracy reported on the Health Department’s pro-
gram and in particular discussed the measles vac-
cine program. He also discussed the suggested sched-
ule of immunizations which was published by the
Medical Association two years ago and indicated that
it will probably be necessary to update this schedule
in the very near future. This will be done by the
South Dakota Pediatric Society and the information
forwarded to the physicians of South Dakota. A mo-
tion was made by Dr. Tracy, seconded and passed,
that the Council be requested to take a definite stand
on encouraging measles immunization clinics, at the
district level.
Dr. J. A. Anderson has just returned from the Rural
Health Conference; however he was not able to at-
tend the meeting and therefore the executive secre-
tary was asked to contact Dr. Anderson to report on
the conference. This report should be made prior to
the Council meeting so that Dr. Gregg might in-
clude it in his report to the Council.
The meeting concerning Socio-Economics in Medi-
cine, sponsored by the AMA was discussed. Drs.
Gregg and Brogdon attended the conference in Chi-
cago and indicated that this area of medicine is be-
coming of vital importance to the physicians. Mr. Er-
ickson was asked to include an item in the Grab Bag
pointing out the article on this subject published in
the March 13th issue of Modern Medicine. Next fol-
lowed a discussion of the reports from Drs. Knabe
and J. W. Donahoe concerning the conference on
Medical Education which was held in Chicago re-
cently. It was pointed out that South Dakota physi-
cians will have to become increasingly aware of the
necessity for continuing re-education through various
programs and re-evaluation of the quality of service
given by practicing physicians by the State Medical
Boards.
Comprehensive health planning was discussed at
some length by the committee. It was the feeling of
the group that perhaps the Council should appoint
a three man ad hoc committee on comprehensive
planning to act in the same capacity as the ad hoc
committee on Title 19. It was requested that Mr.
Erickson write to Dr. Van Heuvelen on the recent
conference held in Pierre, on comprehensive plan-
ning and to report to Dr. Gregg any information re-
ceived from Dr. Van Heuvelen.
Dr. Robert Hayes was introduced to the group as
the Program Director for Heart, Cancer and Stroke
and Dr. Hayes discussed the program as he sees it
at the present time. He also discussed the possibility
of Heart, Cancer and Stroke being tied in with com-
prehensive health planning and also into the area
of medical education. A discussion was held on the
possibility of the four year medical school utilizing
a new concept in medical training. This would be
that students would complete their first two years
of medicine at the school in Vermillion and then work
with instructors in clinical practice for the last two
years of their education.
The subject of the tuberculosis control in the State
of South Dakota, under the direction of Dr. Belzer
was discussed briefly. There was nothing new to re-
port.
An inquiry directed to Doctors Brogdon and Jones
regarding the developments in the selection of the
Dean for the School of Medicine at the University
of South Dakota, revealed that there still has been
no definite decision in this matter.
Dr. Knabe spoke briefly concerning the liaison be-
tween the Medical School and the Medical Associa-
tion through the Medical School Affairs Committee.
It was the feeling that until the new Dean for the
Medical School has been picked and established in
office, it will not be possible to decide much from the
standpoint of this committee and therefore definite
action in this matter will have to await the arrival of
the new Dean. After the Dean has been selected, it
will be possible to establish some policy for meetings
with the Commission on Medical Service which is
the Medical School Affairs Committee.
Information was sought from Dr. Knabe as to
whether the Medical School is utilizing the services
of the Clinical Teaching Staff of the Medical School
on the various committees of the Medical School. As
of this date, there has been very little representation
on the Medical School committees by members of the
Clinical Faculty. This is one area where the Medical
School can improve its relationship with the prac-
ticing physicians of this state.
Prior to the meeting of the Commission on Medical
Service, the meeting of the Medical School Endow-
ment Fund Committee, Inc., was attended by a quor-
um and J. B. Gregg, M.D. It was moved, seconded
and passed unanimously by this committee that “the
Endowment Association make available up to $5,000
to the University Medical School to be used in the 9
to 1 federal matching program starting in fiscal year
1968, for the perpetuating student loan program. Said
school will make an accounting to the Endowment
Association for disposition of these funds.”
There being no further business, the meeting ad-
journed at 1515 hours.
J. B. Gregg, M.D., Chairman
Commission on Medical Service
March 23, 1967
John Gregg, M.D.
318-D West 18th Street
Sioux Falls, South Dakota
Dear Doctor Gregg:
I am sorry to have missed the meeting at Vermil-
lion. I planned to attend but a backlog of patients
combined with being on call and several mechanical
difficulties interrupted the trip.
47 —
This meeting was held in Charlotte, North Caro-
lina because Doctor Washburn was retiring from the
Rural Health Program after being on it for ten years.
His home is Boiling Springs which is near Char-
lotte. It was a unanimous conclusion that they would
never have another meeting in Charlotte; the ac-
commodations were terrible. Five hundred odd people
assembled with about sixty doctors; this was the
biggest meeting they have had and it was mentioned
that about twelve doctors usually attend the meet-
ings. About fifteen of these doctors were in active
practice. Most of the people were Home Economics
ladies, State Extension service leaders and State Ex-
tension health specialists. The topic subjects and
language was directed at these people.
The meeting was divided into four areas: Number
one “Understanding the Interdependence of Rural
and Urban Areas for Improvement of the Health of
People.” This subject was approached by an epidemi-
ologist and another Ph.D. that was head of the West
Virginia Center for Appalachian studies. They had a
government grant to study the model city program
and came to the conclusion that they would develop
three communities with high schools which would
then be entitled to a community with a university
on a trade school level. Three of these such areas
would be entitled to a university on a four year level
and three of these areas would be entitled to a post-
graduate type university. It is too early to come to
any conclusion as to this type of planning.
The second stated purpose: “To Develop Plans and
Utilize more Efficiently Manpower.” This field was
divided into forums; I attended the one on Health
Services. We spent most of the time discussing the
nursing program on Medicare, with the visiting
nurse especially. Their opinion was that this pro-
gram would use the nurse that is not being used
now; that is the one between the ages of 25 and 35.
They could spend two to four hours daily visiting
people in their homes. Someone from Duluth, Min-
nesota mentioned the pilot program with Blue Shield
and Blue Cross making up 50% of the bill for visit-
ing nurse and they thought that it was working out
quite well. This report will be included in the final
report and I think it would be worth reading.
Third was the purpose to discuss and be able to
implement the utilization of community health re-
sources. This was discussed by several farm maga-
zine editors, newspaper, radio and television report-
ers. They came to the conclusion that doctors should
make more of an attempt to use these media for
transmitting health messages and they went into de-
tail as to how they had set up programs for farm
safety, automobile safety and ambulance driver
training programs.
Number four was the purpose to assess the effect
of environmental factors on the health and well be-
ing of people with emphasis on first aid instruction
and approved rural emergency medical care. It seems
that the whole program last year was built around
the assumption that more people die in rural areas
because of lack of immediate care than die in
the urban areas. The speaker thought that one of the
answers to this program would be to mount radio
transmitters on all rural vehicles that would start
sending out a homing signal as soon as it was in an
accident, run out of gas, etc. He stated that the Col-
lins Radio Corporation in Iowa had a government
grant to carry on such a study. The conclusion of this
portion of the program was that there is no present
method of evaluating health or well being.
The program, other than the above mentioned
features, was very similar to the socio-economic
meeting on health care held in Chicago attended by
Doctor Gregg. It was helpful to have read these pa-
pers before going to these sessions. This entire pro-
gram will be published for reading later and I hope
that it makes more interesting reading than it did
listening.
Yours very truly,
J. A. Anderson, M.D.
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Path CAP sule
Submitted by the College of American Pathology in
connection with the South Dakota Society of Pathol-
ogists.
SERUM CREATININE
Creatinine determinations in clinical medi-
cine serve as one of the best indicators of the
status of the functioning kidney. Creatine (me-
thylguanidoacetic acid), the precursor of crea-
tinine, arises in the body primarily by synthesis.
In the kidney, the amide portion of arginine
combines with glycine to form guanidoacetic
acid which is then methylated in the liver to
form creatine. This is transported to muscle
where it is phosphorylated to phosphocreatine,
the source of energy in muscle contraction. Ap-
proximately 2% of the muscle phosphocreatine
is converted to creatinine daily and excreted
from the body almost exclusively by the kidney.
A creatinine value as is ordinarily reported
is the sum of those substances in serum or plas-
ma filtrates which produce a red color by re-
action with alkaline picrate (Jaffe reaction). Ac-
tually, all of the reacting substances are not
true creatinine; however, in renal disease the
elevation of serum “creatinine” is mainly due
to true creatinine.
Creatinine is a by-product of muscle metabo-
lism and is produced at a very constant rate.
The amount excreted in the urine is so constant
that it may be used to check the accuracy of 24-
hour urine collections. Normal amounts ex-
creted in 24 hours usually fall between 1.0 and
2.0 grams3. Since the kidney glomeruli repre-
sent the only significant route of excretion of
creatinine from the body, an increased serum
concentration usually reflects impaired renal
function. Rapidly progressing muscular diseases
may also increase the plasma creatinine level;
however, these maladies are seldom associated
with chronic renal disease. Clinically they are
not difficult to distinguish from kidney disease
and should not complicate the interpretation of
renal function tests. Other conditions that cause
increased protein catabolism do not affect the
serum creatinine concentration significantly.
For example, hemorrhage into the gastrointes-
tinal tract which causes an elevation of blood
urea nitrogen does not increase serum creatin-
ine level. While the creatinine level is independ-
ent of diet and muscular activity, extrarenal
factors can cause elevated creatinine values.
Prerenal azotemia can be caused by reduced
renal blood flow and is seen in congestive heart
failure, salt and water depletion caused by
vomiting, diarrhea, excessive sweating or ex-
cessive diuresis and in shock. Post-renal azo-
temia can be caused by any obstruction of the
urinary tract. The degree will depend upon the
completeness and duration of the obstruction.
Because the blood urea nitrogen has a wide
range of normal values and fluctuates with vari-
ables unrelated to kidney disease, tests based
upon creatinine metabolism provide more spe-
cific information on renal function and chronic
renal disease. The serum creatinine is also a
more sensitive indicator of renal disease than
the blood urea nitrogen, since as little as 40%
reduction of renal function should be reflected
in rising creatinine levels, while the blood urea
nitrogen shows a statistically significant eleva-
tion only after renal function is reduced about
75%. Steadily increasing creatinine levels over
a period of time are indicative of progressive
renal destruction. Within limits, the amount of
destruction is somewhat proportional to the
serum creatinine concentration. It should be rec-
ognized that uremia causes about 30% reduction
in creatinine production; therefore, in advanced
renal disease the serum creatinine levels will
indicate better renal function than actually ex-
ists.
The serum creatinine is of less value in acute
renal disease such as acute renal failure, acute
nephritis, etc. A clearance test, preferably the
creatinine clearance, is the only acceptable
chemical method of measuring renal function in
acute disease.
The normal range of creatinine usually varies
from 0.6 mg% to 1.0 mg% in women and from
0.8 mg.% to 1.2 mg.% in men1. Values over
1.5 mg.% definitely indicate impairment of ur-
ine formation or excretion2. Low serum creatin-
ine values have no clinical significance. Since
the concentration is independent of diet, the
patient need not be fasting when the blood is
obtained for analysis. No allowances have to be
made for body weight and body surface when
an individual is being serially tested. Minor
changes in concentration are of significance be-
cause usually only small fluctuations are en-
countered in an individual.
Other metabolites such as sulfate, phosphate
and urate may be elevated in chronic renal dis-
ease, but their measurement has no advantage
over the plasma creatinine determination.
— 50 —
MAY 1 967
Material needed for the test: fasting or non-
fasting plasma or serum (serum is pre-
ferred); amount 3 ml.
REFERENCES
1. Medical Clinics of North America, Vol. 47, p. 861,
July 1963.
2. Miller, A Textbook of Clinical Pathology, 6th Edi-
tion, p. 239.
3. Standard Methods of Clinical Chemistry, Vol. 3,
p. Ill, 1961, Academic Press.
PATIENT CARE ONE OF 4 TOPICS OF
GENERAL SESSIONS AT 1967
AMA ANNUAL CONVENTION
Patient care, from the standpoint of standard
methods as well as research, will be one of four
topics presented in general scientific sessions
at this year’s Annual Convention of the Ameri-
can Medical Association.
The Convention is to be held in Atlantic City
June 18-22; the Scientific Program will be at
Convention Hall, and nearby hotels, and the
House of Delegates will meet at the Chalfonte-
Haddon Hall Hotel.
The General Scientific Meetings are open to
all physicians attending the Annual Convention.
Other General Scientific Meetings on this
year’s Annual Convention program will be on
the subjects of: backache, healing and sex.
In addition to the General Sessions, each of
the 22 Scientific Sections will present scientific
programs. Many of the Section programs will,
as in past years, be joint meetings of two or
more Sections and, in some instances, a special-
ty society.
Specialty societies joining AMA Sections will
include:
— The American College of Chest Physicians,
which will join the Section on Diseases of the
Chest for a program.
— The American College of Cardiology, which
will join the Section on Internal Medicine in a
session.
— The Society for Investigative Dermatology,
Inc., which will hold its meetings in conjunc-
tion with the Section on Dermatology.
ETHICAL RESPONSIBILITIES IN
PRESCRIBING DRUGS AND DEVICES*
It is unethical for a physician to be influenced
in the prescribing of drugs or devices by his
direct or indirect financial interest in a phar-
maceutical firm or other supplier. It is immater-
ial whether the firm manufactures or repack-
ages the products involved.
* Adopted by the Judicial Council, American Medi-
cal Association, March 12, 1967.
It is unethical for a physician to own stock or
have a direct or indirect financial interest in a
firm that uses its relationship with physician-
stockholders as a means of inducing or influ-
encing them to prescribe the firm’s products.
Practicing physicians should divest themselves
of any financial interest in firms that use this
form of sales promotion. Reputable firms rely
upon quality and efficacy to sell their products
under competitive circumstances, and not upon
appeal to physicians with financial involve-
ments which might influence them in their pre-
scribing.
Prescribing for patients involves more than
the designation of drugs or devices which are
most likely to prove efficacious in the treat-
ment of a patient. The physician has an ethical
responsibility to assure that high quality pro-
ducts will be dispensed to his patient. Obvi-
ously, the benefits of the physician’s skill are
diminished if the patient receives drugs or de-
vices of inferior quality.
Inasmuch as the physician should also be
mindful of the cost to his patients of drugs or
devices he prescribes, he may properly discuss
with patients both quality and cost.
Two well-established general practitioners
would like to help third physician interested
in having his own practice. We desire close
association without partnership.
Excellent chance to enjoy the benefits of
solo practice as well as the advantages of as-
sociation. No salary or other strings attached.
Potential — Overpowering! New practice
can gross $45,000 to $55,000 within three
years. Population of Sioux Falls 74,000 with
large drawing area. One of the real beauty
spots in the Midwest. Hunting and fishing
year round within an hour’s drive from the
heart of town.
Sioux Falls is fortunate to have two general
hospitals which can accommodate up to about
700 patients. There is also a Veteran’s Hospi-
tal, in addition to a Crippled Children’s Hos-
pital.
Wonderful opportunity for the right man.
If interested, please reply to:
Don R. Salmon, M.D.
504 South Cleveland
Sioux Falls, South Dakota 57103
51
The Mediatric Age:
There is a growing senescent body of people on their
way to malignant inactivity, who sorely need your
interest and direction to help them back to a more active
and useful life. There are medicines too, designed to help.
One such has proved useful in clinical practice.
‘ A steroid-nutritional compound
( Mediatric ) was used in 1 00 patients to
relieve some of the symptoms caused by
degenerative changes of aging ...This
therapy resulted in improvement of
75 per cent of the patients . . .”
McNeill, A. J.: Clin. Med. 8:5 18 (Mar.) 1961.
“Mediatric ( steroid-nutritional compound )
capsules , one a day, seem to give definite help
to debilitated patients.”
Arnold, E. T., Jr.: Geriatrics 72:612 (Oct.) 1957.
“Nutritional and hormone bolstering of
function in the aged may have a useful place
in geriatrics.”
Morgan, A. E: Gerontologist 2:77 (June) 1962.
“In diets which for any reason are restricted
in calories, enough of these substances
(B vitamins ) may not be supplied ...The use
of B and C vitamin supplements may then be
justified and indeed may be necessary.”
Morgan, A. F.: Gerontologist 2:77 (June) 1962.
“Intensive nutritional therapy is necessary,
especially in elderly people, to correct dietary
deficiencies created by large losses of protein,
vitamins and other nutrients.”
Riccitelli, M. L.: J. Am. Geriatrics Soc. 72:489 (May) 1964.
MAY 1967
THE MONTH IN WASHINGTON
Washington, D. C. — The American Medical
Association favors utilizing medicaid instead
of expanding medicare.
Dr. Charles Hudson, AMA president, outlined
the Association’s position at a House Ways &
Means Committee hearing on the Administra-
tion’s bill “Social Security Amendments of
1967” (H.R. 5710). He was accompanied by Dr.
Milford O. Rouse, AMA president-elect.
“Available tax funds should be used to give
maximum health care to those who need help,”
Dr. Hudson said. “Expenditure of public funds
on those who do not need help limits the re-
sources available to those who do need it . . .
“We believe that a properly administered
Title 19 (medicaid) with realistic criteria of eli-
gibility designed for economcally disadvantaged
persons, plus the encouragement and improve-
ment of voluntary health insurance and pre-
payment plans for the solvent, provide the best
approach to health care financing.”
Dr. Hudson said AMA representatives would
be glad to meet with the committee and other
interested parties to hammer out a workable
approach to solving the many complex prob-
lems in the medicare program, particularly as
concerns its Plan B.
“Unfortunately, Part B did not receive an
amount of public or congressional debate war-
ranted by the nature and scope of the pro-
posal,” he said. “This committee is now con-
fronted with many problems inherent in the
vast undertaking of the federal government in
becoming directly involved in the total health
care of almost 20 million persons.
“We believe it is possible for the Congress,
the medical profession and others interested in
the subject to develop a new mechanism for de-
livering medical care to people over 65 that
would be more consistent with existing private
sector mechanisms . . .”
Dr. Hudson said that carriers, physicians, pa-
tients, and the government all are dissatisfied
for various reasons with Part B. He said one
possible solution might be to substitute for the
Part B program a subsidy to all eligible persons
for the purchase of private insurance.
Highlights of AMA’s testimony included:
Section 125, to include the disabled.
The adoption of Section 125 . . . could change
the direction of medicare from a program for
older persons to one aimed at various select
categories . . . We believe Title 19 should be
utilized for that purpose.
We urge the Committee to reject this pro-
vision.
Section 127, including podiatry.
While recognizing the usefulness of podiatry
services, we are impelled to note that if the
amendment is adopted, the podiatrist could as-
sume responsibility for the care of some of the
more difficult problems in medicine. We believe
this to be unsound.
Section 130, creation of Part C of Title 18.
This section would provide a new Part C to
cover payment for hospital services rendered to
hospital outpatient; and for diagnostic specialty
services to both outpatients and inpatients of
hospitals.
The AMA opposes Part C in toto . . .
Section 131, physician certification.
The AMA endorses Section 131 which would
remove the requirement of a physician’s certi-
fication for inpatient hospital care for each Med-
icare patient admitted to a general hospital. We
urge the Committee to consider this amendment
favorably and remove an unnecessary impedi-
ment to the operation of Part A.
We further urge that the requirement for re-
certification be similarly deleted, since this need
should be satisfied as a result of the work of
utilization review committees.
Until re-certification is deleted, we suggest
that the first certification date be the 20th day
of hospitalization, as permitted in the existing
law.
Section 220, income maximum under Title 19.
The AMA supports the concept of limiting
eligibility for Title 19 benefits to persons who
genuinely need financial assistance in meeting
their health care needs.
Section 226, free choice under Title 19.
Although free choice is guaranteed for Title
18 recipients, a similar privilege was not ex-
tended to Title 19 beneficiaries. We believe this
was an oversight, and we heartily support this
perfecting amendment to Title 19.
Additional amendments proposed by the
AMA.
First, the AMA recommends that Title 18 be
55 —
SOUTH DAKOTA
amended to permit payment of charges for pro-
fessional services on the basis of a physician’s
itemized statement of charges rather than a re-
ceipted bill.
Second, we recommend that Title 18 be
amended to remove the requirement for three
days of hospitalization before qualifying for ex-
tended care benefits.
In addition, we offer a recommendation re-
lating to psychiatric care under Title 18.
Regarding Title 19, we offer six amendments.
First, that the program permit payment to
the patient for services rendered to him by a
physician on the basis of the physician’s item-
ized statement of charges.
Second, that the program clearly provide for
the payment of physician fees on the basis of
his usual and customary charges, using the
same approach as that applied under Title 18.
Third, that Title 19 encourage the use of in-
surance carriers in the implementation of state
programs.
Fourth, that in the implementation of Title
19 programs, there be no requirement for cer-
tification or re-certification.
Fifth, that Title 19 permit all state plans to
vary the eligibility standards within a state to
recognize the very real differences in the cost
of living in a rural area, a small town, a city
or a metropolitan area.
Our sixth recommendation relates to the fact
that Title 19 benefits differ for mentally ill
patients depending on whether they are above
or below age 65. We believe there should be no
distinction in the services available to mentally
ill patients.
Physician coverage under Social Security.
We believe that physicians, having been
brought under Social Security coverage, should
be accorded the same privilege and opportunity
for reaching a fully insured status as was ac-
corded other professional groups when they
were included in the program.
Accordingly, we urge this Committee to con-
sider the adoption for physicians of an “alterna-
tive insured status” similar to that permitted
by the amendments of 1954 and 1956 which
brought into the program many new groups of
people and professional self-employed persons,
including lawyers.
Take five...
Labstix® provides 5 important urinary find-
ings*—on a single reagent strip! That’s more
information than you can get from any other
single reagent strip. You know the results in
just 30 seconds — while the patient is still in
your office — and readings are reliable and re-
producible. Labstix is easy to handle, too.
Never goes limp, even when wet, because it’s
made with clear, firm plastic. And results with
Labstix are easy to read — color contrast be-
tween the test areas and the transparent plas-
tic is clearly defined. An unexpected “positive”
from testing with Labstix may help in de-
tecting hidden pathology before marked
symptoms are manifest.
*Blood; ketones; glucose; protein, and pH.
AMES COMPANY (R\
Division Miles Laboratories, Inc.
Elkhart, Indiana 465 14 AmeS
Note: AMERICAN HOSPITAL FORMULARY SERVICE
CATEGORY NUMBER 36:88 40167
56 —
1 907 — 60TH
ANNIVERSARY YEAR— 1967
COMMENTARY
From
THE UNIVERSITY OF SOUTH DAKOTA SCHOOL OF MEDICINE
Edited by: Dr. Charles R. Gaush, Publications Committee
THE NEW WING
A consultant site-visit was made at the School of
Medicine on March 27-28 by representatives of the
USPHS. The purpose of the visit was to discuss plans
concerning the proposed new construction at the
Medical School. The addition will be an extension of
two of the present south wings with a connecting
east-west section.
A larger Histology-Pathology lab will be incorpor-
ated in the ground floor and the present lab will be
divided into several office-labs and a Pathology mu-
seum. The construction will also provide two addi-
tional cubicles in the Gross Anatomy lab. The re-
mainder of the ground floor will be used for an audio-
visual laboratory and office-labs for new faculty
members.
The most prominent feature of the first floor ex-
tension will be an amphitheater-type lecture hall
with a seating capacity of approximately 240 per-
sons. This theater will be equipped with a projection
booth for showing slides and motion pictures and will
have adequate storage rooms adjacent to it. It is
designed so that it can be used without entering the
present building.
The principal features on the second floor will in-
clude larger teaching labs for Microbiology-Biochem-
istry and Physiology-Pharmacology. The present labs
are designed for 44 students and provide insufficient
space for our present class of 49. A Virology-Tissue
Culture section is planned for the space presently
occupied by the Microbiology-Biochemistry teaching
lab.
Enlargement of the present building will make it
possible to increase our class size and ultimately pro-
vide a greater number of physicians for South Da-
kota.
FACULTY PROMOTIONS
President Edward Q. Moulton recently announced
the promotion of Dr. George C. Rinker from Associ-
ate Professor to Professor of Anatomy. Dr. Rinker
excels in the teaching of Gross Anatomy and uses
the closed circuit TV system extensively for instruc-
tional purposes. He was recently named to administer
a $26,000 NFME Grant for the further development
of educational television. Dr. Rinker contributes much
of his time as a member of the Admissions Commit-
tee as well as the Loans and Scholarships Committee.
He also finds time to carry out research projects on
the telemetering of electromyographic information
from indwelling electrodes and the comparative my-
ology of the lower animals.
Dr. Moulton also announced that Dr. James N. Ad-
ams, Assistant Professor of Microbiology, was pro-
moted to the rank of Associate Professor. He has been
associated with the School of Medicine since 1963 and
won the Brookings Clinic Award in 1965. As a mem-
ber of the University Faculty Council, Chairman of
the Medical Library Committee and a member of the
Loans and Scholarships Committee, he serves the
school with distinction. In addition to his teaching
duties, Dr. Adams carries out basic research in the
field of microbial genetics and is the recipient of a
Career Development Award from the National In-
stitutes of Health.
HEART-CANCER-STROKE PROGRAM
Dr. Robert H. Hayes, Coordinator of the South Da-
kota Heart-Cancer-Stroke Program, has been ap-
pointed to the staff of the Medical School where his
office is now located. This program, which has
evolved from the “DeBakey Plan,” proposes that each
region of the U. S. decide what it needs to establish
a treatment center for heart, cancer, and stroke pa-
tients.
Dr. Hayes indicated that the physicians themselves
must determine what is needed for South Dakota and
plans to visit each physician personally during the
next year in an effort to develop the most suitable
program for our state. To assist in this planning
phase, Dr. Hayes will distribute a questionnaire that
will provide him with necessary information. He will
also consider all of your ideas and opinions which
may be sent to him prior to his personal visit. Your
cooperation in this matter will be greatly appreci-
ated.
59 —
Sleep-interfering
anxiety and tension
can usually be relieved
with
EQUANIL
(meprobamate) Wyeth
' /
I ' ^ # ¥ &
Cautions: Carefully supervise dose and amounts
prescribed, especially for patients prone to overdose
themselves. Excessive prolonged use may result in
dependence or habituation in susceptible persons—
as ex-addicts, alcoholics, severe psychoneurotics.
After prolonged high dosage, drug should be with-
drawn gradually to avoid possibly severe with-
drawal reactions including epileptiform seizures.
Side effects include drowsiness and, rarely,
allergic or idiosyncratic reactions. These reac-
tions, sometimes severe, can develop in patients
receiving only 1 to 4 doses who have had no
previous contact with meprobamate. Mild reactions
are characterized by urticarial or erythematous
maculopapular rash. Acute non-thrombocytopenic
purpura with petechiae, ecchymoses, peripheral edema
and fever have been reported. Meprobamate should be
stopped and not reinstituted. Severe reactions, observed very
rarely, include angioneurotic edema, bronchial spasms, fever,
fainting spells, hypotensive crises (1 fatal case), anaphylaxis, stomati-
tis and proctitis (1 case) and hyperthermia. Warn patients of possible
reduced alcohol tolerance. Should drowsiness, ataxia, or visual distur-
bances occur, dose should be reduced. If symptoms persist, patients
should not operate vehicles or dangerous machinery. A few cases of
leukopenia, usually transient, have been reported following prolonged
dosage. Other blood dyscrasias— aplastic anemia (1 fatal case),
thrombocytopenic purpura, agranulocytosis and hemolytic anemia-
have occurred rarely, almost always in the presence of known toxic
agents. One fatal case of bullous dermatitis following intermittent
use of meprobamate with prednisolone has been reported.
Prescribe very cautiously for patients with suicidal tendencies.
Suicidal attempts should be treated with immediate gastric
lavage and appropriate supportive therapy.
Contraindications: History of sensitivity to meprobamate.
Composition: Tablets, 200 mg. and 400 mg. mepro-
bamate. Coated Tablets, Wyseals® Equanil
(meprobamate) 400 mg. Continuous-Release
Capsules, Equanil L-A (meprobamate) 400 mg.
Wyeth Laboratories
Philadelphia, Pa.
GUIDEPOSTS FOR THE ADVANCEMENT
OF MEDICINE — 1987
There was recently held in Chicago a confer-
ence on Socio-Economic Problems in Medicine.
The physicians of this state might well be in-
formed of the thoughts expressed at this meet-
ing because the philosophies expounded fore-
tell the course of medicine in the not far dis-
tant future. The speakers who presented their
concepts to a large audience which was com-
posed of some practicing physicians, teachers in
medical schools, hospital administrators, nurses,
directors of clinics and various medical institu-
tions, were not censored by the AMA. They rep-
resented the fields of sociology, political science,
hospitals and hospital planning associations,
medical schools, the military, the Blue Cross,
commercial insurance companies, and research
institutes concerned with this subject. The con-
ference was divided into four sessions, each one
a half day long. (Orientation and Overview; The
Hospital and Its Changing Role in Health Care;
Mobilizing Health Manpower; Financing of
Health Care Services). It had originally been
planned for about 250 participants, but because
of an unexpectedly large demand arrangements
at the last moment were changed to allow about
800 to attend.
Two basic concepts became immediately ap-
parent to an observer attending the session: (1)
The social planners are now in the driver’s seat
insofar as the development of medicine in this
country is concerned, (2) The medical schools
are going to be the nucleus around which medi-
cal care in the states and in the communities
will be developed in the future.
Strong emphasis was put upon the need for
and the expansion of training facilities for vari-
ous medical and para-medical personnel and im-
proved methods of continuing education for
these persons so as to constantly update meth-
ods of treatment. To supplement the shortage
of physicians several avenues were explored.
These included the development of the “assist-
ant physician” or the “physician assistant,” a
person with restricted training and who would
be delegated restricted authority to treat pa-
tients, supervised by an M.D.; delegation of
greater authority to nurses, to include delegat-
ing to them uncomplicated obstetrical deliver-
ies and greater discretion in administering
drugs; employing the training and skills of the
pharmacists in the treatment of patients to a
greater extent than they are now being utilized.
Nursing itself will probably undergo consid-
erable change and result in two large categor-
ies of personnel: (1) those who undertake train-
ing which leads to a baccalaureate degree and
the R.N., and (2) those who take lesser training
and then fit into technical rather than super-
visory capacities. This latter group would in-
clude persons skilled in ward care, OR special-
ists, anesthetists and other special fields. Ad-
ditional training facilities for those in physio-
therapy, X-Ray technology, nutrition, labora-
tory technology, occupational therapy, medical
social work, and other special departments of
health care can be promoted if community col-
leges as well as state supported institutions de-
velop training schools.
The medical staffs are going to have to take
the responsibility for careful reviews of the
quality of medical care in their hospitals (ef-
ficiency committees or medical audits). This
will include both the care rendered by the phys-
icians and that given by the ancillary personnel.
To review their own therapeutic results the
medical staffs have several avenues which are:
(1) A statistical approach, (2) Record review, (3)
Practice observation. Utilization and medical
audit committees employed as educational
mechanisms for the improvement of patient
care and medical techniques, not as punitive
committees, will increase in prevalence and
62 —
MAY 1967
probably become mandatory in all hospitals if
accreditation is desired. There will be increased
emphasis on in-hospital training and continu-
ing education of their personnel. Hospital
bylaws, rules and regulations in the future will
be subjected to close scrutiny, should be up-
dated frequently, and be made very explicit in
all areas. The leadership of the medical staff of
hospitals will need much updating. To promote
continuity in the improvement of medical care,
chiefs of staff in the future will have to be
picked very carefully with more emphasis on
qualification and less on political expediency.
Terms of office greater than a single year for
officers of the medical staffs and the sections
would help promote continuity in the improve-
ment of patient care. Some thought should also
be given to the idea of selection by the hospital
governing board of the Chiefs of Staff or the
employment of a full-time paid physician “med-
ical director.” The possibility of full-time sal-
aried chiefs of the major services in hospitals
must also be considered.
There will be increasing emphasis on the con-
cept of the community health center, especially
in small communities. This center will include
the hospital with all of its facilities, the nursing
home, the physicians’ offices, the pharmacy, the
offices of the ancillary paramedical personnel
such as the psychologist, the sociologist, speech
therapist, audiologist, the hearing aid dispenser,
and others who may in any way relate to the
medical care of patients. Statewide planning for
a community health center program has already
been started in Oklahoma (Project Responsibil-
ity) and a prototype is now beginning operation.
Under the Oklahoma program there will be def-
inite professional and monetary incentives for
young physicians to enter practice in small com-
munities and for the communities to contribute
to the development of the health care center.
There will also be a strong stimulation and a
definite time allowed for the practicing phys-
icians in the small communities to keep up to
date by frequent visits to the medical school at
Oklahoma City where they will teach as well as
be taught. Consultation in the local communi-
ties by visiting consultants from the University
and rapid access to the University Hospitals by
helicopter for emergency or urgent cases from
the community health center is planned.
Although much of the material presented
here may appear to be a Utopian dream to the
physicians of South Dakota, these things are
much closer than most realize. There is already
envisioned and some funds are available in this
state for the development of educational facili-
ties for the physicians through closed circuit or
educational television, under the auspices of the
Heart-Cancer-Stroke program. The educational
TV equipment and facilities have been avail-
able to the School of Medicine and at the Uni-
versity of South Dakota for the past three years.
All that is needed now is the micro-relay equip-
ment and transmission towers so that the entire
state can be bracketed by educational TV. Sur-
veys to determine areas of need and the need it-
self in the treatment of patients having diseases
involving heart, cancer and stroke, “and related
disorders” will be started in South Dakota soon
under the nationwide program which has now
commenced operation. After the investigations
are completed there will come specific recom-
mendations for the better care of patients who
have these and other afflictions.
There is now operative in South Dakota a
plan for the medical treatment of a large seg-
ment of the population in community health
centers somewhat similar to that envisioned for
the communities of Oklahoma. These are the
U.S.P.H.S. Indian Hospitals where many of the
services contemplated in the Oklahoma plan,
are available to the Indian people. The services
of visiting consultants as well as physicians in
residence at the hospitals are accessible to these
people. Other more limited health care plans are
operated by some of the larger industries of this
state. Community health care for small towns
is still not in operation here. However, there is
a need for improved health care facilities in
many small towns. This will have to be seri-
ously considered by the physicians.
The ideas of change will undoubtedly be un-
pleasant to some who now practice medicine in
South Dakota. However, many of the ideas for
improvement in health care are good. In their
development there will be pitfalls, obstacles,
disappointments. Times are changing and the
physicians will have to adapt or fall by the way-
side. If the physicians of this state do not seize
the initiative and take measures to improve
health care, starting at once, it will be forced
upon the medical community by patients
through the federal government. The South Da-
kota State Medical Association might contem-
plate sending a delegate (ion) to Oklahoma or
to the USPHS Indian Hospitals or both to study
the plans being evolved with the idea of trying
to improve the quality of medical care in the
whole state.
John B. Gregg, M.D.
63
SOUTH DAKOTA
"THE HELPING HAND"
A program of vital importance to school age
children and their parents is well under way in
Sioux Falls. Known as “The Helping Hand Pro-
gram” its symbol is a yellow hand on a black
background.
The primary purpose of this program is to
protect children on their way to and from school
and school-related activities.
The symbol bearing placard is displayed in
the window of a home or business. Each such
place is first thoroughly screened by the Police
Department and PTA officials in each school
district. To qualify as a member displaying the
placard, the individual must agree to leave his
or her door unlocked during school hours, and
to arrange to have an adult present during that
time. He or she must further agree to tend only
to the immediate needs of the child seeking as-
sistance and to call for professional assistance
immediaiely.
The placard’s simplicity is for the benefit of
the young, non-readers. They can see at a glance
the yellow hand and will immediately associate
the hand with getting help. This can be taught
to pre-schoolers as well.
While the program is primarily aimed at pro-
tecting the children from child molesters, it is
hoped that it will also help to prevent bullying
of the younger children by the older ones. It
will be beneficial in cases of injuries incurred
en route to school or home as well.
All too often people in less populous areas
tend to become complacent with regard to the
possibility of child molestation. Perhaps if they
were to ask their local police department for a
count of the “known child molesters,” they
would have a rude awakening. For example,
one of South Dakota’s larger cities has over 300
“known” sex deviates, of which some 100 can
be classified as child molesters.
A program of this type can be instituted any-
where — it need not be limited to the larger
cities. It is a worthwhile effort which can be
undertaken by any active PTA or service or-
ganization. What about your community?
LETTER TO THE EDITOR
March 3, 1967
Mr. Dick Erickson
South Dakota Medical Association
711 North Lake Street
Sioux Falls, South Dakota
Dear Dick:
I thought you might like some of these facts
and figures being sent to the membership. It
was sent to me from the National Association
of State Mental Health Directors.
The Federal Budget for our Mental Health-
Mental Retardation next year is $1.4 Billion.
Medicare-Medicaid has risen to a new high of
$353,000,000.
The NIMH budget nears $350 million mark
and tops the Veterans Administration for the
first time. The department of Defense spends
$58 million in Mental Health and Mental Re-
tardation for servicemen and dependents. Also,
$8.5 million goes into the Mental Health pro-
gram in the War on Poverty.
We might like to know that the Veterans Ad-
ministration has about $340,792,000 invested,
which is proposed for 1968. The NIMH has a
$348,640,000 that they are going to expend,
which is an increase of $45,525,000 over last
year.
Now the topper that we have in this total Fed-
eral spending, of course, is $1,428,453,154.
Insofar as Community Mental Health Centers
and Federal grants are concerned, we are one
of the seven states who were approved in the
fiscal year of 1967.
There is $80,000,000 still unallocated in this
situation. I thought maybe you could wheel this
in and if you want to put my signature after it,
fine, if not, it doesn’t make a bit of difference
to me, but I thought maybe some of our mem-
bers would be interested in the factor of money.
Sincerely,
Richard B. Leander, M.D.
RBLimp
— 64 —
“TkiA iA if cur
MEDICAL ASSOCIATION
News Notes • Changes • Births • News
Pop's Proverb
Let it be said, “I failed, but not
for want of trying.”
LENZ NAMED
TO BANK BOARD
B. T. Lenz, M.D., president
of the Huron Clinic, was re-
cently appointed to the Advi-
sory Board of the Huron
Branch of the National Bank
of South Dakota.
Doctor Lenz, a native of
Conde, South Dakota, gradu-
ated from the University of
Minnesota Medical School in
1936. He is a director of the
Huron Chamber of Commerce
and is active in both the South
Dakota Medical Association
and the American Medical
Association.
^ ^ ^
Rapid City internist, Reu-
ben Bareis, M.D., was named
delegate to the 11th Annual
Meeting of the American So-
ciety of Internal Medicine by
the South Dakota Society of
Internal Medicine.
5*C ^
John T. Elston, M.D., Rapid
City, has been re-elected
chairman of the Pennington
County Board of Health for
another one-year term, and
will continue to serve as coun-
ty health officer.
S. F. MAN NAMED
SALESMAN OF THE YEAR
FOR PITMAN-MOORE
Russell Bonacker of Sioux
Falls has been named Sales-
man of the Year for the Pit-
man-Moore Division of The
Dow Chemical Company.
Among the criteria used
were sales increases in both
pharmaceuticals and biologi-
cals, support of the complete
promotional program and of
district objectives, contribu-
tions to the company’s Im-
prove Quality program, and a
good safety record.
YOUR
CONTRIBUTION
TO THE
SOUTH DAKOTA
MEDICAL SCHOOL
ENDOWMENT
FUND
IS NEEDED
The newly elected officers
of the Fourth District Medical
Society are as follows:
President, S. B. Simon, M.D.,
Pierre.
Vice President, E. H. Collins,
M.D., Gettysburg.
Secretary - Treasurer, J. T.
Cowan, M.D., Pierre.
^ ^ ^
A postgraduate course en-
titled “Counseling in Marri-
age Problems for Physicians
and Clergy” will be held at
Estes Park, Colorado, June 19-
23, 1967. The course is being
presented by the Department
of Medicine and Religion of
the American Medical Associ-
ation and the Committee on
Medicine and Religion of the
Colorado Medical Society in
conjunction with the Office of
Postgraduate Medical Educa-
tion of the University of Col-
orado School of Medicine. The
tuition for the five-day confer-
ence is $80.00. For a physician
and a clergyman who register
together, the combined tuition
is $120.00.
* * 5-S
R. E. Shaskey, M.D., Brook-
ings, addressed the Third Dis-
trict Medical Society at their
February meeting. He spoke
on drug therapy in convulsive
disorders and treatment of
meningitis.
— 69 —
SOUTH DAKOTA
William H. Griffith, M.D.,
former Huron physician, died
recently in California. Doctor
Griffith was associated with
the Sprague Clinic in Huron,
later reorganized as the Hur-
on Clinic.
He left Huron in 1940 to join
Buell H. Sprague, M.D. in a
clinic in Hollywood, Califor-
nia. He was still engaged in
medical practice at the time of
his death.
Doctor Griffith is survived
by his widow, a brother, and
two sisters. He was preceded
in death by a son who was
killed while serving with the
U.S. Air Force in Kingsville,
Texas.
H5 H5
James S. Lydiatl, M.D. re-
cently attended a postgradu-
ate course at the New Orleans
Medical Society.
Sfc %
An informative booklet en-
titled, “What you should
know about Schizophrenia,”
has been made available by
the American Schizophrenia
Foundation. It is available for
50 cents from the Foundation,
230 Nickels Arcade, Ann Ar-
bor, Michigan 48108.
❖ * *
VA PROMOTES VOTAW
TO R. I. POST
Frederick L. Votaw, M.D.,
chief of staff at the Royal C.
Johnson Veterans Hospital in
Sioux Falls has been pro-
moted to chief of staff at the
Veterans Administration hos-
pital at Providence, R. I. Doc-
tor Votaw had been with
the Sioux Falls VA Hospital
since 1962. A A ^
DIS'N'DATA
THE BONY PROBLEM —
The anatomy of any associa-
tion or club includes four
kinds of bones: (1) wish bones,
who want someone else to do
the work; (2) jaw bones, who
talk a lot but do little else; (3)
knuckle bones, who knock ev-
erything others try to do, and
(4) back bones, who get behind
the wheel and do the work.
E. S. Watson, M.D., Brook-
ings, recently moderated the
18th annual Pastoral Counsel-
ing Institute sponsored by the
South Dakota Mental Health
Association.
The Institute is designed as
a postgraduate educational
conference in counseling. Dis-
cussion leaders were Roy C.
Knowles, M.D., Sioux Falls;
Dr. Charles R. Stinnette, Jr.,
Professor of pastoral theology
at the University of Chicago
Divinity School, and Father
Adrian Kaam, Professor of
psychology at Duquesne Uni-
versity.
^ ^ $
John O'Sullivan, M.D., for-
merly of Hoven, South Dako-
ta, has moved to Redfield,
South Dakota. He is now as-
sociated with E. J. Perry, M.D.
and M. E. Sanders, M.D.
Blessed event?
Not entirely, when nausea and
vomiting occur in early pregnancy.
Emetrol offers prompt and safe
relief. Local rather than systemic
action provides emesis control on contact with the hy-
peractive G.I. tract.* In a study of 123 pregnant women,
the drug produced measurable improvement in 79% of
patients in controlling vomiting.1
*As shown by in vitro studies.
1. Crunden, A. B., Jr., and Davis, W. A.: Am. J. Obst. & Gynec.
65:311 (Feb.) 1953.
WILLIAM H. RORER, INC.
Fort Washington, Pa.
Emetrol®
phosphorated carbohydrate
solution
emesis control
70 —
OVT H
HhALi N SCItNC-tb USBKAiNV
UNIVERSITY OF MASRYUW#
BALTIMORE
CIRCULATES
DAKOTA
Something special
Darvon* Compound-
Each Pulvule® contains 65 mg. propoxyphene hydrochloride,
227 mg. aspirin, 162 mg. phenacetin, and
32.4 mg. caffeine.
S
.dditional information available
licai profession upon request.
Eli Lilly and Company
Indianapolis, Indiana 46206
700610
what
PARKE-DAVIS
for control of
allergic symptoms
I 1811
Whether the allergen is greenish or garish, unseen or
unknown, your patient can get symptomatic relief with
BENADRYL— the potent antihistamine with antispas-
modic action. INDICATIONS: Antihistaminic, anti-
spasmodic, antitussive, and antiemetic therapy.
PRECAUTIONS: Persons who have become drowsy
on this or other antihistamine-containing drugs, or
whose tolerance is not known, should not drive
vehicles or engage in other activities requiring keen
response while using this product. Hypnotics, sed-
atives, or tranquilizers if used with diphenhydramine
hydrochloride should be prescribed with caution
because of possible additive effect. Diphenhydramine
The pink capsule with the white band is a trademark
of Parke, Davis & Company.
has an atropine-like action which should be con-
sidered when prescribing diphenhydramine hydro-
chloride. ADVERSE REACTIONS: Side effects are
generally mild and may affect the nervous, gastro-
intestinal, and cardiovascular systems. Drowsiness,
dizziness, dryness of the mouth, nausea, nervousness,
palpitation, blurring of vision, vertigo, headache,
muscular aching, thickening of bronchial secretions,
restlessness, and insomnia have been reported.
Allergic reactions may occur.
BENADRYL is available in Kapseals® of 50 mg. and
Capsules of 25 mg. ooee?
Le »***»»*
■ to help restore and stabilize
the intestinal flora
■ for fever blisters and canker
sores of herpetic origin
LACTINEX contains both Lactobacillus acid-
ophilus and L. bulgaricus in a standardized viable
culture, with the naturally occurring metabolic
products produced by these organisms.
First introduced to help restore the flora of
the intestinal tract in infants and adults, li 2- 3’ 4
LACTINEX has also been shown to be useful in the
treatment of fever blisters and canker sores of
herpetic origin.5,6’7,8
No untoward side effects have been reported to
date.
Literature on indications and dosage available on
request .
References:
(1) Siver, R. H.:
CMD, 22:109,
September 1954. (2)
Frykman, H. H.: Mina.
Med., 35:19-27,
January 1955. (3)
McGivney, J.: Tex.
State Jour. Med.,
51 : 16-18, January
1955. (4) Quehl,
T. M.: Jour, of Florida
Acad. Gen. Prac.,
23:15-16, October
1965. (5) Weekes,
D. J.: N.Y. State Jour.
Med., 35:2672-2673,
August 1958. (6)
Weekes, D. J.: EENT
Digest, 23:47-59,
December 1963. (7)
Abbott, P. L.: Jour.
Oral Surg., Anes., &
Hosp. Dental Serv.,
310-312, July 1961.
(8) Rapoport, L. and
Levine, W. I.: Oral
Surg., Oral Med. &
Oral Path., 20:591-593,
November 1965.
HYNSON, WESTCOTT
& DUNNING, INC.
BALTIMORE, MARYLAND 21201
( L.XQ4 )
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
Volume XX June, 1967 Number 6
CONTENTS
New Challenges and New Responsibilities 17
L. C. Duncan
Medical Costs: Rapid Rise Causing Government Concern 23
Elinor Langer
Heart Disease, Exercise and Serum Glutamic-Oxalacetic Transaminase . 27
Jerry B. Critz, Ph.D.
Ligamentous Injuries of the Ankle and Knee 41
Robert E. Van Demark, M.D., F.A.C.S.
Medical-Legal Implications for Medical Staff Officers and Committees . 45
John Bailey Gregg, M.D.; Theodore Mead Bailey, Jr., LL.B.
PathCAPsule 49
Commentary 51
Editorial *53
Letters 54
This Is Your Medical Association 59
Second Class Postage Paid at Sioux Falls, South Dakota
Published monthly by the South Dakota Medical Association, Publication Office
711 North Lake Avenue, Sioux Falls, South Dakota 57104
S.D.J.O.M. JUNE 1967 - ADV.
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balanced to minimize the chance of constipation or laxation
and still achieve rapid acid neutralization and pain relief.
■ The positive action of simethicone helps relieve the pain-
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■ The nonfatiguing flavor and smooth, nongritty consistency
of tablets and liquid encourage continued patient coopera-
tion during long-term therapy.
Composition: Each Mylanta chewable tablet or teaspoonful (5 ml.)
of liquid contains: magnesium hydroxide, 200 mg.; aluminum hydrox-
ide, dried gel, 200 mg.; simethicone, 20 mg. Dosage: one or two tab-
lets, well chewed or allowed to dissolve in the mouth, or one or two
teaspoonfuls of liquid to be taken between meals and at bedtime.
The Stuart Company, Pasadena, California
Division of Atlas Chemical Industries, Inc.
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
SUBSCRIPTION $2.00 PER YEAR SINGLE COPY 20c
Volume XX June, 1967 Number 6
STAFF
Editor Robert Van Demark, M.D. Sioux Falls, S. D.
Assistant Editor Judith Perkins Schlosser Sioux Falls, S. D.
Associate Editor Robert Thompson, M.D. Yankton, S. D.
Associate Editor Gordon Paulson, M.D. Rapid City, S. D.
Associate Editor Gerald Tracy, M.D. Watertown, S. D.
Business Manager Richard C. Erickson Sioux Falls, S. D.
EDITORIAL COMMITTEE
R. E. Van Demark, M.D., Chr. ... Sioux Falls, S. D.
J. A. Anderson, M.D. Madison, S. D.
G. E. Tracy, M.D. Watertown, S. D.
W. R. J. Kilpatrick, M.D Huron, S. D.
Hugo Andre, M.D. Vermillion, S. D.
H. B. Munson, M.D. Rapid City, S. D.
R. F. Thompson, M.D. Yankton, S. D.
John B. Gregg, M.D. Sioux Falls, S. D.
PUBLICATIONS COMMITTEE
R. E. Van Demark, M.D., Gordon Paulson, M.D., Robert Thompson, M.D., W. T. Sweeney,
M.D.
OFFICERS
South Dakota State Medical Association
President _ P. Preston Brogdon, M.D. Mitchell, S. D.
President-Elect John Stransky, M.D. Watertown, S. D.
Vice-President J. T. Elston, M.D. Rapid City, S. D.
Secretary-Treasurer A. P. Reding, M.D. _ Marion, S. D.
Executive Secretary Richard C. Erickson Sioux Falls, S. D.
Delegate to A.M.A. A. P. Reding, M.D. Marion, S. D.
Alternate Delegate to A.M.A. R. H. Quinn, M.D. Sioux Falls, S. D.
Chairman Council E. T. Lietzke, M.D. Beresford, S. D.
Speaker of The House J. P. Steele, M.D. .... Yankton, S.D.
Sioux Valley Medical Association
President C. J. McDonald, M.D. Sioux Falls, S. D.
Secretary Daniel Youngblade, M.D. Sioux City, Iowa
Treasurer Karl Wegner, M.D. Sioux Falls, S. D.
NEW CHALLENGES
and
NEW RESPONSIBILITIES
Text of Speech by
L. C. DUNCAN
Chairman of the Board
PHARMACEUTICAL MANUFACTURERS ASSOCIATION
at the
68th ANNUAL CONVENTION
of
THE NATIONAL ASSOCIATION OF RETAIL DRUGGISTS
Tuesday, October 25, 1966
Kiel Municipal Auditorium
St. Louis, Missouri
There is an old saying in Wall Street that the
only safe prediction about the future of stock
prices is that they will fluctuate.
The action of the stock market in recent
months has taught a good many of us the wis-
dom of that old maxim.
I, for one, intend to keep it firmly in mind
this morning in discussing the future of the
drug business. In fact, the only broad predic-
tion I am willing to make is that there are many
changes in store for us as we enter this new
era of medical care. What they will all be, I
don’t pretend to foresee.
There is, however, one fundamental change
already in the making which I do know some-
thing about and which concerns me deeply. It
is one that will impose a new and heavy burden
of responsibility on every one of you in the
pharmacy and retail drug field.
I am referring to the rising tide of what, for
want of a better name, I will call “bootleg
drugs.” By drugs, I do not mean narcotics. I
mean the steroids, the antibiotics, the diur-
etics and the whole broad field of ethical phar-
maceutical products with which you are all so
familiar. Under “bootleg” and “bootleggers” I
include the smugglers, the counterfeiters, and
all the illicit makers and purveyors of drugs of
unknown or unspecified origin.
As some of you may know, I have been com-
pelled by circumstance to acquire some know-
ledge of pirating and other criminal activities
in the drug field because my company has been
one of the unhappy victims of their depreda-
tions.
The theft of cultures which produce antibi-
otics, and of processes and know-how for the
manufacture of other drugs; the smuggling of
pharmaceutical products from abroad and
across the borders of Canada and Mexico — these
activities have received considerable publicity
because of recent court cases. Most of you have
probably heard something about them.
Fortunately, a hot pursuit by the F.B.I. and
successful prosecutions by the Department of
Justice have put a number of these criminals
behind bars, where they are spending their time
repenting their sins — or, more likely, plotting
new ventures, for reasons I’ll tell you about
later.
But these events, important in themselves,
are only a prelude to what I fear is the begin-
ning of a turbulent time in the drug field. What
disturbs me is that in many ways it bears an
ominous resemblance to the Prohibition Era of
the Twenties.
The smuggling of pharmaceutical products
from abroad is not new. Nor is their theft, illicit
manufacture in the United States and distribu-
tion through subterranean channels. Even the
counterfeiting of capsules and tablets of well-
known brands, and the illegal reproduction of
their exact labels and packages have been
taking place on a minor scale for a long time.
The point is that in the past such activities have
been insignificant.
Why? Because there was little or no market
for such products.
What has changed is that the market for un-
branded drugs of uncertain origin has increased
17 —
SOUTH DAKOTA
enormously. A former market measured, at
most, in the hundreds of thousands of dollars
now has a potential of many millions.
In the past, doctors, druggists and hospitals,
with no facilities for testing the products them-
selves, placed their reliance on the name of the
drug manufacturer as a guarantee of potency,
purity and safety. It did not matter whether the
maker was large or small, or whether he sold
his products under brand names or generic
names.
What did matter was that over a long period
of years the manufacturer had built up and
jealously guarded his reputation for high qual-
ity products, exacting inspection procedures,
effective research, and, in general, the conduct
of a highly ethical business.
One of my competitors has a slogan which
expresses the matter succinctly: “Our integrity
— the priceless ingredient.”
The physician, the pharmacist and, most im-
portantly, the patient, placed their reliance on
this integrity and ethical conduct — and it sel-
dom let them down.
This safeguard which heretofore has served
us so well is now under attack and is in danger
of being demolished. It began with an assault
by the Kefauver Committee on drug prices and
brand names and was given great impetus by
the Drug Amendments of 1962 which followed
those hearings.
One of the principal purposes of the new
Amendments, according to their sponsors, was
to bring down drug prices. This they proposed
to do by placing full responsibility on the Food
and Drug Administration for seeing to it that
all drugs available on the market, from any
source, were fully potent, pure and safe. This
desirable objective was to be accomplished by
the registration of drug manufacturers, testing
and inspections, and general policing activities.
Relying on these new safeguards, the govern-
ment and others have instituted a program to
promote the use of unbranded drugs on the
grounds that with the proper inspection, pre-
sumably now provided, one drug is as good as
another, regardless of source, and price should
be the only consideration.
You may well ask: “And what is wrong with
that? Isn’t the Food and Drug Administration
adequately staffed and fully qualified to cope
with the enforcement problem?”
I won’t attempt to answer that directly. But
I will say that if I had the job of Chief Enforce-
ment Officer I am afraid that the spectre of the
old Volstead Prohibition Act would rise to
haunt me.
To begin with — in order to inspect anything
you first have to find it. I would recall the army
of “revenooers” combing the misty “hollers” of
the Kentucky hills in a vain attempt to locate
the source and dam the flow of illegal booze.
The locale of these new drug operators is not
the remote areas of the southern Appalachians,
but the industrial “badlands” of New Jersey
and the jumbled factory and warehousing areas
on the outskirts of cities like Chicago and De-
troit. Hidden away among legitimate businesses
and protected by respectable fronts, these new
illicit enterprises are even more difficult to lo-
cate than the old bootleg stills.
Secondly, these new policing problems will
require the recruitment and training of an en-
tirely new type of enforcement personnel.
Heretofore, the chief requirement for an
F.D.A. inspector was some technical knowledge
of pharmaceutical products and their methods
of manufacture and inspection. In many cases
he worked with the plant manufacturing staff
to improve the techniques and controls to in-
sure high quality products, as well as to police
those already in use. Compliance with the rules
and regulations was not difficult to enforce be-
cause the manufacturer’s good name was his
chief stock-in-trade: he could not afford to
jeopardize it by adverse publicity even if he
were reluctant to comply with particular re-
quests.
The new entrepreneurs in the drug business
are an entirely different breed. To find, super-
vise and control their activities will require not
scientifically and technically trained personnel,
but a large force of pistol-packing investigators
skilled in underworld procedures.
A final problem which would concern me is
that, while there are methods of determining
potency for most drugs on the market, no bat-
tery of tests on the finished product has ever
been devised which would enable one to certify
that it is completely pure and safe.
In fact, over the years experience has demon-
strated that the only real assurance of highest
quality products requires the purchase of the
purest ingredients available; the individual test-
ing of each batch of raw material by the drug
manufacturer, regardless of how many certifi-
cates of quality are provided by the supplier;
sampling of batches while in various stages of
manufacture by an independent control center;
the use of the latest electronic devices to pre-
18
JUNE 1967
vent mistakes in filling and labeling; and a
quarantine of the final product while all the
tests are re-run before it is released for sale.
If there are any shortcuts to these exacting
procedures to insure high quality products we
have not found them.
This situation was summed up by Dr. C. A.
Morrell, for many years Director of the Food
and Drug Directorate in Canada (corresponding
to our own F.D.A.), who stated in his testimony
before a special parliamentary committee con-
cerned with the quality of drugs:
“I am loath to have people say that a
drug is guaranteed by the Food and Drug
Directorate. I do not see how we can
guarantee it. There are many subtleties
and we do not have the facilities to detect
the differences . . . you cannot put ‘gov-
ernment approved’ on a drug. It is wise
to buy on the reputation of a company.
You do that in purchases of other items,
and I think one is wise to do it with drugs.
“If I were a doctor prescribing I am sure
I would tend to prescribe from companies
I know.”
The gentlemen who run the rackets and ne-
farious business enterprises in the United
States are already well aware of the new op-
portunities which have been opened up for
them in the field of pharmaceutical products.
The features which attract them are all present
In fact, a criminal prospectus might read some-
thing like this:
ESSENTIALITY — Drugs for treating dis-
eases fulfill an urgent human need — as
do prostitution, gambling, narcotics and
other activities which have always been
so profitable.
MARKET POTENTIAL — Can be esti-
mated as high as a hundred million dol-
lars.
PRIMARY CUSTOMERS— Federal agen-
cies, city, county and state hospitals and
all other medical groups and programs
financed by public funds because regula-
tions already in effect, or likely to be
written, require that their purchasing be
done on the basis of competitive bidding.
Purchase at the lowest price offered is
mandatory unless there are good and suf-
ficient reasons for rejecting the lowest
bidder.
POTENTIAL CUSTOMERS — Private
hospitals, drugstores, and even dispens-
ing doctors as they participate in Medi-
care and state public assistance programs,
and yield to official pressure to buy and
prescribe on a generic basis.
METHOD OF OPERATION — Fits well
with other activities. Permits use of dum-
my corporations to hide the origin of pro-
ducts, the employment of respectable
fronts for distributing them, and the ap-
plication of the usual persuasive methods,
where necessary, to secure new customers
and the continued patronage of old ones.
POSSIBLE PENALTIES— Negligible. Vi-
olations are only a misdemeanor and the
penalty, withdrawal of the product and
a small fine. F.D.A. inspectors cannot
make arrests. They must persuade a
United States attorney to issue a search
warrant and have Federal marshals serve
it and make arrests, if warranted.
Only the actual counterfeiting of regu-
lar pharmaceutical products and traffic
in narcotics, goofballs (amphetamines),
barbiturates, and like products, carry
heavier penalties.
Some of you may think that I have exagger-
ated in order to make a point. However, one
of the people who has already had some con-
siderable experience with trying to cope with
these activities is Dr. Roscoe P. Handle, Com-
missioner of Health of the State of New Jersey,
which is a hotbed of illicit drug manufacturing.
Let me quote from a report written by him.
“We know from companies we have
closed that there exists the menace of in-
dividuals who operate under the guise of
respectability and who produce, distrib-
ute and sell dangerous drugs illegally.
These individuals use unskilled labor to
manufacture expensive, highly complex
drugs, often in dilapidated factories un-
der filthy, grossly unsanitary conditions.
The drugs are made without proper
checks and balances or quality control
and usually there is no record of what
went into their manufacture . . . These
new-style racketeers keep little or no
record of distribution and sales. By this
device they can avoid detection and tax-
ation . . . Without hesitation they will
infringe patents, imitate and counterfeit
standard brands, smuggle materials from
abroad . . .
19
SOUTH DAKOTA
“They select only the most profitable
drugs and recently have turned to tran-
quilizers, diuretics, cortisone products,
cardiac stimulants and others.
“The individuals engaged in these unlaw-
ful operations know how, when and
where to unload their products at a sub-
stantial profit. Government agencies,
anxious to buy drugs in large quantities
at low cost, are especially susceptible.”
You may wonder why you have heard so little
thus far about such activities. The answer is
that this final chapter is just beginning. The
full story is yet to be written but the outline
of the form it will take is very clear indeed.
Looking back over the events of the past
several years, it seems almost incredible that
we should have arrived at the point where we
stand today.
It is difficult to say where it all began. One
of the convicted culprits claims that he really
started what has been almost a chain reaction
by conceiving the idea that drugs could be
bought cheaply abroad and supplied to the U. S.
Defense Department at bargain prices which
would be attractive to them. He apparently as-
sumed — rightly, as it turned out — that the
Defense Department would invoke its special
privileges and ignore any patents in the United
States. I might add that this individual is bitter
about the fact that someone else (according to
his version) stole his idea, froze him out and
kept him from profiting from it.
In any case, the Defense Department did be-
gin to buy drugs from Italian companies as
early as 1959, lured by the savings which were
offered by the foreign products. This action by
an agency of the United States Government had
these consequences:
1) It provided a lucrative market for for-
eign drugs paid for in hard dollars;
2) It cloaked the activities of pirate drug
firms operating in a patent sanctuary
with a measure of respectability;
3) It highlighted the differential in price
between the products of well-known,
ethical companies and those from for-
eign sources.
Thus, the controversy over drug prices began.
There are those among my colleagues who
would say, “Yes, the prices of our drugs are
high when compared with those offered in a
thieves’ market.”
“Yes, they are high when the prices quoted
by companies who spend millions of dollars on
research, clinical testing and inspection proced-
ures are compared with those offered by firms
who do none of these things but cut every cor-
ner to produce only the popular forms of the
most widely-used products.”
Those on the other side of the controversy re-
tort that they are also high when measured by
the mark-up over manufacturing costs or return
on investment.
I am not here to argue one side or the other.
My role today is only that of a reporter at-
tempting to chronicle and interpret what really
happened.
The initial buying of Italian drugs by the
U. S. Defense Department was soon followed
by the Kefauver Hearings with their great em-
phasis on one point — the substantial mark-up
of drug prices over manufacturing costs. These
events received wide publicity and attracted
great attention throughout the world because of
the pre-eminence of United States firms in the
discovery and marketing of drugs on a global
basis.
The British government started buying cheap
drugs from outside sources for its National
Health Service, and a number of lesser coun-
tries, influenced by the action of two leading
commercial nations like England and the United
States, followed their example.
Encouraged by these developments, the illicit
drug business began to flourish. Cultures which
produce antibiotics, steroids and related prod-
ucts were stolen and sold abroad. Research data
was filched from files and secretly micro-filmed,
as were manufacturing processes and know-
how, and a thriving business in drug espionage
sprang up.
In the beginning, the manufacturing activi-
ties were concentrated in Italy because it is the
only modern industrial nation which does not
provide patent protection for pharmaceutical
products. Later, supplies began to emerge from
behind the iron curtain, channeled through re-
spectable commercial fronts in centers like Am-
sterdam and Zurich to mask the country of ori-
gin.
While these activities abroad have had serious
consequences for the foreign business of many
20 —
JUNE 1967
American firms, their effect on the domestic
drug business has thus far been minor, except
for some smuggling of patented products and
importing of bulk materials.
What is of great significance to our domestic
industry is the mushrooming growth of clan-
destine manufacturing operations in the United
States. Up until recently these illicit operations
concentrated on the production of “goofballs”
and counterfeiting, but the scope of their oper-
ations is now being expanded to include the
whole range of ethical pharmaceutical products.
This illicit branch of the industry is still rela-
tively small. The important thing is that the
seeds have been sown and the method of opera-
tion established. Its rapid growth only awaits
the opening up of the vast new markets which
the campaign for generic prescribing will pro-
vide.
So, here we stand today — with the patent
and trademark system for pharmaceutical pro-
ducts under attack from many quarters.
Largely forgotten is the fact that these vital
factors provide the funds for the private re-
search which has been so enormously produc-
tive and enabled us to lead the world in ethical
drugs. Mostly ignored is the fact that the reli-
ance on trademarks, brand names and voluntary
compliance with the law and regulations has
made it possible to police this vast industry
successfully with a mere handful of technically-
oriented F.D.A. inspectors.
With these pillars gone or seriously weak-
ened, I am concerned, as a drug manufacturer,
with the future of research.
I am alarmed, as a citizen, about the cost of
the vast policing effort which the F.D.A. faces
and whether or not it can succeed at any cost.
And, as a patient at some time in the future,
I will always be worried about the purity, po-
tency and source of manufacture of every drug
administered to me in a hospital or supplied on
prescription.
I have talked in detail to you about these
forebodings — not as an audience. You, as retail
druggists, will play an important part in the
drama that is unfolding.
In fact, there is no audience for this play.
When the curtain falls, it will fall on all of us.
When eating fads
of teens or tots
Lead to a sudden
case of “trots”
Parepectolin for quick relief of acute diarrhea
. . . soothes colicky pain with paregoric*
. . . consolidates fluid stools with pectin
. . . adsorbs irritants with kaolin,
and protects intestinal mucosa
In children, Parepectolin may be used to control
diarrhea promptly and prevent dehydration,
until etiology has been determined. In some
cases, Parepectolin may be all the therapy nec-
essary.
Contains opium (V± grain) 15 mg. per fluid
ounce.
warning: mag be habit forming
Pectin (2% grains) 162 mg.
Kaolin (specially purified) .... (85 grains) 5.5 Gm.
(alcohol 0.69%)
Usual Children’s Dose: One or two teaspoonfuls three
times daily.
RORER
E
R
— 21
WILLIAM H. RORER, INC.
Fort Washington, Pa.
22
S.D.J.O.M. JUNE 1967 - ADV.
:
paid *974,000
in doctor bills
for its members
Blue Shield membership is a genuine bargain: Over 91c out
of every dollar paid in by members is paid back in the form
of receipted doctor bills. No wonder 52 million Americans
protect themselves against unexpected medical-surgical ex-
penses by belonging to Blue Shield. No wonder 300 of the
nation’s 500 largest corporations carry Blue Shield for their
employees.
The unselfish devotion of doctors who serve as Blue Shield
board members and trustees without remuneration is a very
important contributing factor to Blue Shield’s low admin-
istrative expenses.
® Service marks reg. by National
Association of Blue Shield Plans
BLUE SHIELD
THE PROGRAM GUIDED BY DOCTORS
MEDICAL COSTS: RAPID RISE
CAUSING GOVERNMENT CONCERN
Elinor Langer
After several months of study and research
the Department of Health, Education, and Wel-
fare has come up with a report* that confirms
what everyone who has been paying medical
bills knows without being told — that medical
costs are rising, and rising fast. The govern-
ment’s interest in this condition arises from the
fact that, with the passage of Medicare, Medic-
aid, and a number of other new programs, it is
increasingly a bill-paying participant in the
process of medical care and not, as in the past,
merely an interested onlooker. The report is a
trifle weak on recommendations and is frankly
gloomy in its forecast that continued increases
are inevitable. It does not say very much that
experts on medical economics and critics of
American medicine have not been saying for
years. But it is a remarkably lucid, sensible, and
straightforward summary of what is ailing our
medical economy, and its appearance as a gov-
ernment document marks a high point in gov-
ernmental perception of what the problems are.
The facts seem to be simple enough. Accord-
ing to the HEW report, doctors’ fees, which had
been rising at a rate of less than 3 percent per
year, rose almost 8 percent during 1966. Hospi-
tal room rates rose about 16.5 percent, and are
now about $45 a day. Drug prices have not con-
tributed significantly to recent overall increases
in costs, according to HEW’s analysis, but they
do contribute significantly to the high cost of
medical care in general.
The essential reason for the rise in doctors’
fees, according to the report, is “a substantial
and sustained increase in demand without a cor-
‘Medical Care Prices (Superintendent of Docu-
ments. Government Printing Office, Washington, D.C.
20402; 20 cents).
Reprinted with permission from Science, Vol.
155, pp. 1519-1521, 24 March, 1967. Copyright 1967
by the American Association for the Advancement
of Science.
responding increase in supply.” Recent growth
in demand is attributed to many factors, be-
ginning with the simple 28-percent increase in
population between 1950 and 1965. In addition,
the report says that changes in the internal
character of the population have enlarged the
groups that tend to seek medical care — there
are more women, more city dwellers, more edu-
cated people, more children, and more elderly.
The expansion of insurance coverage has also
played a role, as has the public’s conviction that
medical care has become more effective, hence
more desirable.
During the same period (1950-65) the number
of physicians increased by 33 percent. But the
proportion of physicians in private practice de-
clined from 72 to 62 percent; the remainder
work in hospitals, medical schools, and so forth.
And there was a numerical decline in the total
number of family physicians — pediatricians,
internists, and general practitioners — as more
doctors entered specialties.
The doctors responded to this situation partly
by increasing their productivity — seeing more
patients per week, shifting from house to office
visits, increasing their staffs, acquiring complex
equipment, and entering into new organiza-
tional forms such as group practice and partner-
ship. But they increased their fees as well, and
they increased them far faster than the general
rise in the Consumer Price Index.
Hospital Costs
As far as hospital costs are concerned, they
are affected by the same increase in demand
and by the same increase in insurance coverage
that affect the doctors. But HEW says that the
major reason for the price rise is the rise in
wages, which account for two-thirds of the costs
of hospital care. Since the report notes that as
recently as 1963 there were ironers in Memphis,
for example, earning less than 45 cents an hour,
— 23 —
SOUTH DAKOTA
it would seem that any changes in this depart-
ment can only be applauded. The report points
out, however, that the wage increases have not
been “offset by any measurable increase in the
‘productivity’ of hospital employees,” and that
“the number of employees per patient is rising,
not falling.” According to the report, the “non-
wage costs of hospitals are also rising, reflecting
the growing complexity of hospital plant and
rapid increases in the specialized care facilities
available in hospitals.”
The HEW study found that, although the re-
assessment of costs at the time Medicare went
into effect probably made it seem timely to
many hospitals to increase their charges, the
increased occupancy rates engendered by Medi-
care were not in themselves responsible for the
price rises. Increased occupancy does not neces-
sarily result in higher costs per patient. By the
same token, HEW found no evidence that Medi-
care was responsible for the rise in doctors’ fees.
In the drug department, the HEW study re-
ports that, while prices have not risen as rapidly
as have other medical expenses, consumer ex-
penditures on drugs have increased sharply. The
report cites a number of reasons for the rising
expenditures, but stresses chiefly the fact that
more drugs are now available for more pur-
poses. The report says that drugs are now fre-
quently substituted for more expensive forms
of treatment, that the public seems anxious to
buy drugs such as sedatives and tranquilizers
(retail sales of which increased 535 percent be-
tween 1952 and 1965), and that old people, of
whom there are rising numbers, spend about 2.5
times as much money on drugs as do young
people. The cause for concern in this area, ac-
cording to the report, is that “although average
drug prices are not rising appreciably, there is
ample evidence that they are higher than they
would be if there were greater price competi-
tion in the industry, either at the manufactur-
ing or at the retail level. The pharmaceutical in-
dustry,” it points out, “is characterized by high
concentration, high advertising costs, and in-
tense non-price competition.”
What Should Be Done?
HEW believes that, in order to help keep
prices down, changes should be made in six
major areas. First, the department believes that
alternatives to hospital care should be encour-
aged. The report points out that hospital serv-
ices are the most expensive ingredient of the
medical-care bill and that, while most people
now have hospital insurance, “far fewer people
have insurance which covers less expensive
medical care services, such as care in nursing
homes and convalescent hospitals, outpatient
care, or organized home health services.” As a
result, the report continues, “doctors often put
patients in hospitals for diagnosis or treatment
rather than utilizing less expensive alternative
services because a third party will pay the hos-
pital bill.” It adds that in many communities
lower-cost alternatives to hospital care do not
exist.
Accordingly, the department believes that
“comprehensive community health care systems
should be developed, demonstrated and evalu-
ated,” under the auspices of a National Center
for Health Services Research and Development,
recently proposed by the President. It also be-
lieves that group practice should be encouraged
by federal action, and that both private and
public insurance plans should be broadened to
cover more alternative types of health care.
In its second group of recommendations the
report calls for an end to “uncoordinated devel-
opment of health services and facilities [which]
often leads to costly duplication and under-utili-
zation of facilities, as well as to serious gaps in
the availability of health services.” This is, in
short, a call for planning, and the report pro-
poses that individual states create strong plan-
ning agencies “with the power to affect the rate
of expansion of health facilities,” and that the
federal government supply funds to assist the
states in this process.
A third category of recommendations is dir-
ected at “improving the internal efficiency of
hospitals and other providers of health serv-
ices.” The report proposes that the new health
care research center demonstrate ways of re-
ducing costs, and that the government should
attempt to provide incentives to hospitals to in-
crease their efficiency.
The HEW report leaves detailed suggestions
on manpower to the President’s Commission on
Health Manpower, a group that has been at
work on this question for some time, but the re-
port’s main thrust can be summed up in the
word “more.” It also suggests that, in an effort
to use both present and future manpower more
efficiently, attention be given to programs such
as the President’s recent proposal to train phys-
ician-assistants (Science, 17 February 1967).
A fifth category of recommendations — likely
to make the pharmaceutical industry extremely
edgy — calls for “improving the knowledge and
the flow of information on the effectiveness of
drugs.” While this goal seems innocuous enough,
HEW is proposing to implement it in ways that
— 24
JUNE 1967
undercut the present structure of industry sales:
first by studying the possibility of requiring
prescription of drugs by their generic names un-
der government-financed programs; second, by
having the Food and Drug Administration pro-
vide information for doctors on the efficacy and
side effects of drugs. Generic prescription has
been an industry nightmare since Kefauver,
and the drug lobby — in evident anticipation of
new governmental moves — has recently stepped
up its campaign against it. The suggestion that
FDA give doctors drug information directly
would have the effect of reducing the phys-
icians’ present near-total reliance on the com-
panies for supplying that information, and
might have consequences the industry would
find equally unwelcome.
Finally, the HEW report calls for “a continu-
ing national effort to improve the efficiency of
medical care delivery,” proposing by way of
implementation a national conference on medi-
cal-care costs and a continuing monitoring of
medical prices by HEW and the Department of
Labor.
On the whole, it has to be said that the report
is considerably longer on analysis than on spe-
cific proposals to end the rise in medical prices.
For the most part its proposals are for the more
forceful implementation of existing federal
authority, not for more powers. There is a heavy
preponderance of calls for cooperation, consul-
tation, and conferences. Whether these gentle
means will be effective it is hard to judge — the
report itself betrays very little optimism on this
score. But at least, for the first time, the people
and institutions that are raising their charges
will know that somebody out there is watching
them.
Vacation trip
Motion sickness?
This time it’ll be different. Emetrol taken before the
trip begins will usually prevent nausea and vomiting.
Emetrol is effective and safe... most helpful where safe-
ty is most important. It acts locally— not systemically.
WILLIAM H. RORER, INC.
Fort Washington, Pa.
Emetrol®
phosphorated carbohydrate
solution
emesis control
25 —
26
S.D.J.O.M. JUNE 1967 - ADV.
Look how many ways
Thorazine’
brand of
chlorpromazine
can help
Tranauilizer
Potentiator
Antiemetic
Agitation
•
Alcoholism
•
•
Anxiety
•
Cancer patients
•
•
•
Severe
neurodermatitis
•
Drug addiction
withdrawal symptoms
#
•
Emotional disturbances
(moderate to severe)
•
Nausea & vomiting
•
•
Neurological disorders
•
Obstetrics
•
•
#
Pain
•
•
•
Pediatrics
•
•
•
Porphyria
•
•
Psychiatric disorders
•
H i c c u p s— ref ra cto ry
•
Senile agitation
•
Surgery
•
•
•
Tetanus
•
•
‘Thorazine1 is useful as a specific adjuvant in the above
named conditions.
The following is a brief precautionary statement. Before prescrib-
ing, the physician should be familiar with the complete prescrib-
ing information in SK&F literature or PDR. Contraindications:
Comatose states or the presence of large amounts of C.N.S.
depressants. Precautions: Potentiation of C.N.S. depressants
may occur (reduce dosage of C.N.S. depressants when used
concomitantly). Antiemetic effect may mask other conditions.
Possibility of drowsiness should be borne in mind for patients
who drive cars, etc. In pregnancy, use only when necessary to
the welfare of the patient. Side Effects: Occasionally transitory
drowsiness; dry mouth; nasal congestion; constipation; amenor-
rhea; mild fever; hypotensive effects, sometimes severe with
I.M. administration; epinephrine effects may be reversed; derma-
tological reactions; parkinsonism-like symptoms on high dosage
(in rare instances, may persist); weight gain; miosis; lactation
and moderate breast engorgement (in females on high dosages);
and less frequently cholestatic jaundice. Side effects occurring
rarely include: mydriasis; agranulocytosis; skin pigmentation,
lenticular and corneal deposits (after prolonged substantial
dosages).
For a comprehensive presentation of ‘Thorazine’ prescribing
information and side effects reported with phenothiazine deriv-
atives, please refer to SK&F literature or PDR.
Smith Kline & French Laboratories
E R
HEART DISEASE, EXERCISE AND SERUM
GLUTAMIC-OXALACETIC TRANSAMINASE*
Jerry B. Critz, Ph.D.
Associate Professor
Department of Physiology and Pharmacology
University of South Dakota, School of Medicine
Vermillion, South Dakota
Enzymatic transamination was first discov-
ered by Braunstein and Kritsman in 1937 1 , al-
though a non-enzymatic type had been de-
scribed as early as 1930 by Needham2. The pro-
cess of transamination is a chemical reaction in
which an amino group is transferred from an
amino acid to a keto acid without the intermedi-
ate appearance of ammonia. Glutamic-oxalace-
tic transaminase (GOT) catalyzes the reaction
illustrated in Figure 1.
The report which prompted the clinical in-
terest in GOT was that of LaDue, Wroblewski
and Karmen in 1954 when they found an in-
crease in GOT activity in the serum following
an acute myocardial infarction4. Their discov-
ery stimulated widespread investigation of this
phenomena and resulted in the demonstration
that the enzyme increase in the serum was due
to loss of GOT from damaged myocardial cells
in the infarcted area 5, 6.
COOH
C*0
i
$OOH
HCNH,
COOH
hcnh2
COOH
C*0
ch9
1 2
+
CH«
| 2
GOT
^ ch2 +
CH?
COOH
COOH
PYRIDOXAL
PHOSPHATE
COOH
COOH
a- Ketoglutaric
acid
Aspartic
acid
Figure 1
Glutamic acid
Oxalacetic
acid
The coenzyme for most of the transaminase en-
zymes, including GOT, is pyridoxal phosphate3.
When carrying the amino group it exists as py-
ridoxamine phosphate (Figure 2).
CHO
PHOSPHATE
Figure 2
PHOSPHATE
* Presented at the Black Hills Medical Seminar,
Rapid City, South Dakota August 5-6, 1966.
Supported in part by research grant AM-06154
from the National Institutes of Health, USPHS.
The diagnostic value of the SGOT determina-
tion in suspected infarction is great. According
to some authors, a large number of heart in-
farcts, perhaps as many as 1/3, cannot be im-
mediately detected by electrocardiography.
SGOT determination then is the only immediate
and reliable proof of infarction. This is particu-
larly true in cases of repeated infarctions which
are especially difficult to detect on the electro-
cardiogram7, 8.
The enzyme increase in the serum is detect-
able 4-12 hours following onset of symptoms
while maximum activity occurs 24-48 hours aft-
er onset of symptoms. It has been demonstrated
that an infarct involving less than one gram of
myocardial tissue will result in a significant
increase in SGOT9. The serum enzyme level re-
turns to normal within one week in most
cases7. This rapid time course should emphasize
the importance of getting a blood sample early
in the episode, and repetitive samples at close
intervals thereafter. It is particularly import-
27—
ant to determine the peak elevation of transa-
minase activity since this value is proportional
to the size of the infarct9. A rise in SGOT activ-
ity to the range of 200 units is indicative of a
poor prognosis7.
On the basis of their electrophoretic proper-
ties two isozymes of GOT have been identi-
fied10’ 1 1 . One of these isozymes is located in or
on the mitochondria (GOTm) while the other
is restricted to the soluble fraction of the cell
(GOTs). The isozymes are important in that the
type of GOT present in serum normally, as well
as following a myocardial infarct is GOTs. It is
of interest that prednisolone will prevent the
loss of GOTs from the myocardium subjected
to an experimental infarct12. This appears to
have no clinical significance at the present time.
LaDue and his colleagues, when first report-
ing on the elevated SGOT activity associated
with a heart infarct, also noted that there was
a wide range in the SGOT activity in normal
men (4-40 units)13. Another group of investi-
gators pointed out, however, that SGOT activity
was relatively constant in a given individual
from day to day, under normal conditions14. It
will vary in that same individual under special
physiological conditions. The most interesting
circumstance, at least from our view, was the
variation that occurred in response to exercise.
Conflicting reports dealing with this subject
have appeared in the literature. The findings of
this laboratory in 1962 1 5 and 1964 1 6 concerning
a fall in SGOT activity following exercise have
been confirmed in independent laboratories17’
18. Other laboratories, however, have reported
increases in SGOT activity, often into the path-
ological range following exercise19'22. Still
other investigators have completed the spec-
trum of possible results by reporting no change
in SGOT values after exercise23- 24.
The conflicting results reported may be due
to one or more differences in procedure be-
tween these laboratories. For example, most
investigators have studied the SGOT response
to exercise at only one or two different loads;
even more confusing has been the practice of
utilizing different types of exercise. Secondly,
the time for taking a blood sample after exer-
cise has varied considerably; some investigators
take a sample immediately after the exercise,
other investigators will wait until 10 minutes,
60 minutes, or even 24 hours after completing
the exercise. Also, when working with small
animals most investigators take a blood sample
SOUTH DAKOTA
by a direct heart stab. This is satisfactory if
only one blood sample is desired, some investi-
gators, however, have taken repeated samples
by this method. The heart stab is very damag-
ing to the myocardium. Preliminary experi-
ments in our laboratory have revealed a step-
wise increase in SGOT activity following each
heart stab (unpublished data).
Since the SGOT test is widely used to aid in
the diagnosis of myocardial infarction these dif-
ferences must be resolved in order to minimize
the possibility of obtaining a high SGOT value
as a result of exercise rather than a myocardial
infarct. For example, let us consider the case
of a hypothetical man some 50-55 years old
who appears at a hospital emergency room late
Sunday afternoon complaining of a chest pain
similar to that experienced in a coronary oc-
clusion two years previously. The EKG reveals
nothing new but the SGOT test yields a value
of 75 units. A careful history reveals that the
patient spent Saturday morning spading a gar-
den, Saturday afternoon was utilized to mow
and then rake his large lawn and Saturday eve-
ning he and his wife went bowling. The ques-
tion then, is the SGOT elevation related to this
unusual exercise load or to a new myocardial
infarction? Experiments recently reported from
this laboratory may have provided an answer
to such a question25.
The experimental animal utilized was the al-
bino rat. Serum for the SGOT determination
was obtained by a single heart stab on un-
anesthetized, restrained rats immediately after
exercise. The SGOT method used was that of
Babson26 as modified by Furuno and Sheena27.
The animals swam for either 1 min., 5 min., 10
min., 15 min., 30 min., 60 min. or 120 minutes.
In this study we found the duration of swim-
ming time determined the SGOT response ob-
served. Swimming for a very short time (1 min.)
caused a decline in SGOT activity while a five
minute swim resulted in elevation of such ac-
tivity. A 10 or 15 minute swim caused no change
in SGOT activity but longer swimming times
(30, 60 or 90 min.) again resulted in elevated
SGOT activity. It would appear then, that a
heavy work load, or an unusual exercise load,
imposed on man over a period of one day or
more could cause an elevation in SGOT activ-
ity. In such a case SGOT activity should return
to normal in 12-16 hours19. An infarct with ir-
reversible damage to the myocardium would be
marked by a persistent loss of GOT into the
28 —
JUNE 1967
serum (4-7 days) as indicated earlier in this
discussion7.
The mechanism responsible for the SGOT
changes during the first 5 minutes of a swim-
ming exercise is unknown. The elevated SGOT
activity associated with the longer duration
swimming episodes might be due to a hypoxic
condition developing in the active muscles. This
would increase the permeability of the cell
membrane to a degree sufficient to allow leak-
age of GOT into the serum. Such a mechan-
ism has been postulated by other investiga-
tors in this area of research21’ 28-30 Highman
and his colleagues at the National Institutes of
Health have suggested, however, that the hy-
poxic condition may act indirectly by first stim-
ulating release of catecholamines31. These, in
turn, are responsible for the increased perme-
ability. Their hypothesis resulted from studies
on dogs in which they infused large amounts
of norepinephrine or epinephrine. The work of
Gray and Beetham suggests that the doses util-
ized by Highman were far in excess of the phy-
siological release of these catecholamines dur-
ing exercise32.
Our laboratory has introduced data which
may partially explain the SGOT results ob-
served in prolonged exercise. In previous pub-
lications we have demonstrated that rats sub-
jected to strenuous exercise accumulate GOT
in heart, skeletal muscle and liver16. The same
accumulation occurs in the left ventricle of rats
faced with an elevated systemic blood pressure
induced by coarctation of the abdominal aorta
or by administration of DOC A33- 34 . Such an
increase in the tissue levels of GOT would re-
sult in an elevated tissue/serum gradient, thus
favoring diffusion into serum and might ex-
plain the increased serum GOT associated with
the longer duration swimming exercises. Addi-
tional support for the concept has become avail-
able. This laboratory published a paper in 1965
dealing with myocardial and skeletal muscle
transaminase levels in response to exercise aft-
er adrenocortical blockade35. The substance
used to block the adrenal cortex was diphenyl-
hydantoin (Dilantin). The administration of this
drug to normal animals caused an increase in
GOT activity in the heart. Recently Japanese
investigators reported that Dilantin adminis-
tration caused elevation of serum GOT levels36.
It would appear then that Dilantin elevates
heart GOT (quite possibly it has this effect on
other tissues as well) increasing the tissue/
serum ratio and increasing its tendency to dif-
fuse into the serum.
The function of GOT in serum is unknown,
indeed it may have no function there but mere-
ly represent slow leakage from heart, skeletal
muscle and other tissues as a normal occurrence.
Also, the function of the enzyme in heart and
other tissues remains obscure, but it appears to
be closely related to the contractile process,
since the appearance of contractile activity in
the fetal heart coincides with the appearance of
GOT activity37. Cohen has pointed out that the
role of transamination (GOT) appears to be one
of providing a common pathway for glutamic
acid to alpha-ketoglutaric acid38. He also pointed
out that the rapid rate of transamination and
its independence of aerobic conditions indicate
its importance in making alpha-ketoglutaric acid
available for muscle metabolism. This substance
could enter the Krebs Cycle and result in an
elevated production of ATP which would aid
the exercising animal in meeting the increased
work load.
REFERENCES
1. Braunstein, A. and Kritsman, M.: Decomposition
and Synthesis of Amino Acids by Conversion of
Amines; Studies on Muscle Tissues. Enzymologia
2:129-146, 1937.
2. Needham, D.: A Quantitative Study of Succinic
Acid in Muscle. III. Glutamic and Aspartic Acids
as Precursors. Biochem. J. 24:208-277, 1930.
3. Green, D., Leloir, L. and Nocito, V.: Transamin-
ases. J. Biol. Chem. 16:559-582, 1945.
4. LaDue, J., Wroblewski, F. and Karmen, A.: Serum
Glutamic-Oxalacetic Transaminase Activity in
Human Acute Transmural Myocardial Infarction.
Science 120: 497-499, 1954.
5. Lemley-Stone, J., Merrill, J., Grace, J. and Me-
Neely, G.: Transamination in Experimental Myo-
cardial Infarction. Am. J. Physiol. 183:555-558,
1955.
6. Brouhon, N.: Clinical Interest in the Determina-
tion of Serum Transaminase and Lactic Dehydro-
genase. J. Pharmacol. Belg. 16:286-300, 1961. CA
61:9876, 1964.
7. Straus, B. and Plasaj. M.: Changes in Serum
Transaminases in Heart Disease. Lijecnicki
Vjeanik 86:289-297, 1964.
8. LaDue, J., Nydick, I. and Wroblewski, F.: Vari-
ations in Serum Glutamic-Oxalacetic Transamin-
ase Activity Following Experimental and Clinical
Coronary Insufficiency. Circulation 12:736, 1955.
9. Agress, C., Jacobs, H., Glassner, H., Lederer, M.,
Clark, W., Wroblewski, F., Karmen, A. and La-
Due, J.: Serum Transaminase Levels in Experi-
mental Myocardial Infarction. Circulation 11:711-
713, 1955.
10. Borst, P. and Peeters, E.: The Intracellular Local-
ization of Glutamate Oxalacetate Transaminase
in Heart. Biochem. Biophys. Acta 54:188-189, 1961.
11. Morino, Y., Kagamiyama, H. and Wada, H.: Im-
munochemical Distinction Between Glutamic-Ox-
alacetic Transaminases from Soluble and Mito-
chondrial Fraction of Mammalian Tissues. J. Biol.
Chem. 239:PC 943, 1964.
29
SOUTH DAKOTA
12. Huzino, A., Kimura, H., Aburaya, T. and Katun-
uma, N.: Leakage of Aspatate Transaminase from
Dog Heart Muscle After Experimental Myocardi-
al Infarction. J. Biochem. 54:452-454, 1963.
13. Karmen, A., Wroblewski, F. and LaDue, J.: Trans-
aminase Activity in Human Blood. J. Clin. Invest.
34:126-131, 1955. Appendix by Karmen, A.: A
Note on the Spectrophotometric Assay of Glutam-
ic-Oxalacetic Transaminase in Human Blood
Serum. J. Clin. Invest. 34:131-133, 1955.
14. Chinsky, M., Shmagranoff, G. and Sherry, S.:
Serum Transaminase Activity: Observations in a
Large Group of Patients. Clin. Res. Proc. 3:200,
1955.
15. Critz, J. and Merrick, A.: Serum Glutamic-Oxa-
lacetic Transaminase Levels After Exercise in
Men. Proc. Soc. Exp. Biol. Med. 109:608-610, 1962.
16. Critz, J. and Merrick, A.: Transaminase Changes
in Rats After Exercise. Proc. Soc. Exp. Biol. Med.
115:11-14, 1964.
17. Laets, G.: Variations of Serum Transaminase Ac-
tivity During Labour. Proc. IV Intern. Cong. Clin.
Chem. E and S Livingstone, Ltd., Edinburgh and
London, 1961, p. 172.
18. Nerdrum, H. and Nordoy, S.: Changes of Serum
Glutamic-Oxalacetic Transaminase Following Ex-
ercise in Patients With and Without Coronary
Disease. Scand. J. Clin. Lab. Invest. 16:617-623,
1964.
19. Schlang, H.: The Effect of Physical Exercise on
Serum Transaminase. Am. J. Med. Sci. 242:338-
341, 1961.
20. Altland, P. and Highman, B.: Effects of Exercise
on Serum Enzyme Values and Tissue of Rats. Am.
J. Physiol. 201:393-395, 1961.
21. Altland, P., Highman, B. and Garbus, J.: Exer-
cise Training and Altitude Tolerance in Rats:
Blood, Tissue, Enzyme and Isoenzyme Changes.
Aerospace Med. 35:1034-1039, 1964.
22. Nerdrum, H. and Berg, K.: Changes of Serum
Glutamic-Oxalacetic Transaminase and Serum
Lactic Dehydrogenase on Physical Exertion.
Scand. J. Clin. Lab. Invest. 16:624-629, 1964.
23. Halonen, P. and Konttinen, A.: Effect of Physical
Exercise on Some Enzymes in the Serum. Nature
193:942-944, 1962.
24. Swaiman, K. and Awad, E.: Creatine Phospho-
kinase and Other Serum Enzyme Activities After
Controlled Exercise. Neurology 14:977-980, 1964.
25. Critz, J.: Effect of Swimming Exercise on Serum
Glutamic-Oxalacetic Transaminase and Hematoc-
rit of Rats. Proc. Soc. Exp. Biol. Med. 121: 101-
104, 1966.
26. Babson, A., Schapiro, P., Williams, P. and Phillips, ;
G.: The Use of a Diazonium Salt for Determina-
tion of Glutamic-Oxalacetic Transaminase in
Serum. Clin. Chim. Acta 7:199-205, 1962.
27. Furuno, M. and Sheena, A.: Adaptation of Bab-
son’s Method for the Determination of Serum
Glutamic-Oxalacetic Transaminase in the Clinical
Laboratory. Clin. Chem. 11:23-28, 1965.
28. Highman, B. and Altland, P.: Serum Enzyme Rise
After Hypoxia and Effect of Autonomic Blockade.
Am. J. Physiol. 199:981-986, 1960.
29. Asvall, J.: Transaminase Activity After Experi-
mental Hypoxia in Rabbits. Scand. J. Clin. Lab.
Invest. 12:239-246, 1960.
30. Highman, B. and Altland, P.: Serum Enzyme
Changes in Dogs Exposed Repeatedly to Severe
Altitude Hypoxia. Am. J. Physiol. 201: 603-606,
1961.
31. Highman, B., Maling, H. and Thompson, E.: Se-
rum Transaminase and Alkaline Phosphatase
Levels After Large Doses of Norepinephrine and
Epinephrine in Dogs. Am. J. Physiol. 196:436-
440, 1959.
32. Gray, I. and Beetham, W.: Changes in Plasma
Concentration of Epinephrine and Norepine-
phrine With Muscular Work. Proc. Soc. Exp. Biol.
Med. 96:636-638, 1957.
33. Critz, J.: Myocardial Transaminase Response to
Elevated Blood Pressure. Steroids 1:445-449, 1963.
34. Critz, J. and Withrow, T.: Myocardial Transamin-
ase Following Coarctation of the Abdominal
Aorta. Proc. Soc. Exp. Biol. Med. 116: 38-40, 1964.
35. Critz, J. and Withrow, T.: Adrenocortical Block-
ade and the Transaminase Response to Exercise.
Steroids 5:719-728, 1965.
36. Tamura, S., Tsutsumi, S., Ito, H., Nakai, K., Gam-
amoto, K., Masuda, M., Nakamura, H., Koide, T.
and Yamada, N.: Side Effects of Diphenylhydan-
toin and Phenylethylacetylurea in Albino Rats.
Nyr. Yakurigaku Z. 61:1 14-130, 1965. Chem. Biol.
Act. 2 (4):132, 1965.
37. Ponomareva, T., Drel, K.: Glutamate-Aspartate
and Glutamate-Alanine Transaminase Activity in
Tissue of Developing Embryos. Biokhimiya 29:
185-190, 1964. CA 61:3487, 1964.
38. Cohen, P.: Transamination with Purified Enzyme
Preparations (Transaminase). J. Biol. Chem. 136:
565-601, 1940.
— 30 —
LIGAMENTOUS INJURIES OF THE ANKLE AND KNEE*
Robert E. Van Demark, M.D., F.A.C.S.
Sioux Falls, South Dakota
Most ligamentous injuries of the ankle and
knee will respond satisfactorily to a regime of
limited activity and protective dressings. Oral
medications and various injections in the af-
fected area are used to reduce the pain and
swelling. Roentgenographic examination is
mandatory to rule out any bony injury.
A small percentage of these twisting, abduc-
tion or adduction injuries do not respond satis-
factorily to the usual treatment. Complete re-
covery does not occur in the usual two or three
weeks. It is this group of cases on which the
present discussion is centered.
At the ankle, the ligaments most commonly
affected are the components of the lateral col-
lateral ligament of the ankle. The anterior talo-
fibular ligament extends from the anterior bor-
der of the fibula to the neck of the talus. The
calcaneofibular ligament runs from the tip of
the fibula to a colliculus on the lateral surface
of the calcaneus while the posterior talofibular
ligament goes from the malleolar fossa of the
distal fibula to the posterior process of the tal-
us. Medially, the strong deltoid ligament fans
out from the medial malleolus to be attached
to the talus, scaphoid and calcaneus.
At the time of injury, complete rupture of
the ligaments of the ankle usually is difficult
to differentiate from a partial rupture or
sprain. Usually, however, the pain and swelling
are more severe and persistent than that seen
in the ordinary sprain. The pain and muscle
* Paper presented at the meeting of the South Dakota
Chapter of the American College of Surgeons on
January 21, 1967 at Huron, S. D.
spasm associated with the injury prevent prop-
er clinical examination for instability. Only aft-
er the patient has been put to sleep and under
anesthesia can the true status of the ankle joint
be ascertained. Ordinary X-rays of the ankle
are routinely negative (Fig. 1).
Fig. 1 - Routine X-ray views were negative after a
severe ankle injury with multiple fractures
elsewhere.
With the patient relaxed, the instability of
the ankle can be demonstrated (Fig. 2). This is
usually due to rupture of the anterior talofibu-
lar and the calcaneofibular ligaments; injuries
to the posterior talofibular ligament are not
common1 .
With early recognition, suture of the injured
ligament is the ideal method of repair and is a
highly successful procedure. In old cases, re-
construction of the ligaments by the method of
Watson-Jones5 has been an extremely effective
procedure and in our experience has held up
well over a period of many years.
— 41 —
SOUTH DAKOTA
Fig. 2 - Stress X-rays showed an unstable ankle
with rupture of the lateral ligaments.
Avulsion of the attachments of the deltoid
ligament due to eversion injuries (Fig. 3) are
infrequent but respond well to early suture and
immobilization in a plaster-of-paris cast for
eight weeks.
Fig. 3 - Avulsion of the deltoid ligament from the
medial malleolus, with a dislocation of the
subtalar joint. Closed reduction of the dis-
location and suture of the avulsed ligament
resulted in normal function.
The ligaments of the knee are composed of
the tibial or medial collateral, lateral or fibu-
lar collateral ligament and the cruciate liga-
ments. The anterior cruciate ligament is at-
tached anteriorly to the non-articulating sur-
face of the upper tibia and extends upward and
backward to attach to the posterior aspect of
the inner surface of the lateral condyle of the
femur. The posterior cruciate ligament is like-
wise named from its attachment to the tibia
where it attaches in the posterior intercondy-
loid fossa and extends upward and forward to
attach to the lateral surface of the medial fe-
moral condyle. The medial or tibial collateral
ligament extends from the medial femoral con-
dyle above to the medial tibial condyle below.
Its deeper fibers, extending from the margins
of the joint, give attachment to the medial men-
iscus. The fibular collateral ligament extends
from the lateral femoral epicondyle to the head
of the fibula below. It has no attachment to the
lateral meniscus, being separated from the lat-
ter by the popliteal tendon.
At the knee, as in the case of the ankle, liga-
mentous injury is often masked by the pain
and involuntary muscle spasm associated with
the injury. The tibial collateral ligament, which
Fig. 4 - Roentgenogram showing tilting of the tibial
surface in a football player after routine
X-ray views were negative.
— 42 —
JUNE 1967
is injured much more frequently than the fib-
ular collateral ligament, may be injured in the
flexed knee without an injury to the anterior
cruciate ligament which stabilizes the knee in
complete extension. On examination, abduction
of the extended knee is not possible with an
intact anterior cruciate ligament. If the knee is
flexed slightly, widening of the joint space of
more than 10 degrees (Fig. 4) is usually diagnos-
tic of an injury to the tibial collateral liga-
ment2. The intact anterior cruciate ligament
will prevent anterior displacement of the tibia
on the femur with the knee flexed at 90 degrees,
the so-called drawer sign, while an intact pos-
terior cruciate ligament will prevent posterior
displacement of the tibia on the femur with the
knee flexed 90 degrees. When the anterior cru-
ciate ligament is injured at the same time as
the tibial collateral, abduction of the extended
knee is possible and can be demonstrated by
X-ray. With involvement of the posterior cru-
ciate in addition, increased abduction is pos-
sible. (Fig. 9).
In contrast to the ankle, delayed ligamentous
repairs of the knee are not too satisfactory, even
in the hands of experts. As emphasized by
O’Donoghue 3, early repair of the ligamentous
Fig. 5 - Same case after attachment of the distal
tibial collateral ligament with a stainless
steel staple. A stable knee resulted.
Fig. 6 - Routine views of this injured knee were
negative.
Fig. 7 - Stress views of the same knee showed a
fracture of the medial femoral condyle in
addition to widening of the joint.
structures is an extremely effective procedure.
Frequently the injury to the anterior cruciate
and tibial collateral ligaments is associated with
a tear of the medial meniscus, the so-called “un-
happy triad”3. Fracture of the medial femoral
condyle4 can be associated with this (Fig. 6, Fig.
7). In repair of the ligaments of the knee, we
have used various means, including staples
(Fig. 5, Fig. 10), pullout wires and chromic su-
tures. Immobilization in a cast with emphasis
on quadriceps setting exercises performed hour-
ly during the day is extremely important in
— 43 —
Fig. 8 - Same case following repair of the tibial col-
lateral and anterior cruciate ligaments and
excision of torn medial semilunar cartilage.
A year later the patient was chosen “all
state guard” on completion of the football
season.
Fig. 9 - With involvement of the posterior cruciate
in addition to the tibial collateral and an-
terior cruciate ligaments, increased abduc-
tion is present.
achieving a good clinical result. The usual pe-
riod of immobilization of six to eight weeks is
required of most ligamentous injuries of the
knee.
SOUTH DAKOTA
Fig. 10 - Late repair of the elongated tibial collater-
al ligament by the method of Black. The
proximal bony attachment of the scarred
ligament is transferred upward and fixed
with staples.
Old ruptures of the ligaments of the knee do
not lend themselves to reconstruction, particu-
larly with associated injuries to the articular
surface of the joints. Certainly no attempts
should be made to reconstruct the ligaments un-
til after the patient has been on a long course of
physical therapy and progressive resistive exer-
cises. No operation can restore the original
structure and function of the ligaments. Recon-
struction of the tibial collateral ligament has
been the most satisfactory repair. Our personal
preference has been the procedure of Black2
(Fig. 10) in which the upper attachment of the
residual scarred ligament is transferred to a
more proximal level on the femur where we
prefer to fix it with two stainless steel staples.
BIBLIOGRAPHY
1. Anderson, K. J., Lecocq, J. F. and Lecocq, E. A.:
Recurrent Anterior Subluxation of Ankle Joint.
J.B.J.S. 34A: 853-86, Oct. 1952.
2. Crenshaw, A. H.: Campbell’s Operative Ortho-
paedics. St. Louis, C. V. Mosby, 1963, Vol. 1.
3. O’Donoghue, D. H.: Treatment of Injuries to Ath-
letes. Philadelphia, W. B. Saunders, 1962, 649 pp.
4. Smith, L. A.: A Concealed Injury of the Knee.
J.B.J.S. 44-A: 1659-1660, Dec. 1962.
5. Watson- Jones, R.: Fractures and Joint Injuries.
Baltimore, Williams and Wilkins, 1955.
— 44 —
MEDICAL-LEGAL IMPLICATIONS
FOR MEDICAL STAFF OFFICERS AND COMMITTEES
John Bailey Gregg, M.D.
and
Theodore Mead Bailey, Jr., LL.B.
Sioux Falls, South Dakota
The position as an officer of a medical organi-
zation or membership on an important commit-
tee comes to most physicians at some time dur-
ing their active professional lives. Accompany-
ing the honour of such positions there is re-
sponsibility and, unfortunately, certain haz-
ards. It is not common knowledge that some
professional liability and malpractice insurance
may be inoperative when the physician is act-
ing in a capacity outside the direct practice of
medicine.
Protection for the best interests of the patient
while he is under medical treatment or hospi-
talized must be the primary purpose of phys-
icians individually, the hospital staffs adminis-
tratively, and medical societies collectively. In
most communities today medical care is ade-
quate and the patient leaves treatment the bet-
ter for it. Occasionally treatment may be less
than optimum. If this is repetitious the elected
officers of the hospital medical staff or the local
medical society may be put into the circum-
stance that they must censure a colleague,
limit his practice or hospital privileges, or per-
haps deny him the privilege of practicing in a
hospital or in the community. This poses thorny
problems, not the least of which is the possibil-
ity of litigation, alleging restraint of trade or
deprivation of means of livelihood. Despite the
fact that such litigation may have little foun-
dation in fact, it may be most embarrassing to
all concerned, costly in terms of time lost, dam-
age to reputation, and potentially very humili-
ating. There is nothing so distasteful or poten-
tially as frustrating to the officer of a medical
society or hospital staff as having the duty
to censure a colleague. Yet this is an obligation
of elective or appointed office made necessary
by the need to constantly improve the quality
of medical care.
Injudicious application of the censure author-
ity and personality conflicts between the par-
ties involved has in the past led to serious re-
percussions. For this reason, the hospital or
medical society officer who is in a disciplinary
situation too often takes the easiest pathway
out of the dilemma which is to whitewash the
offender, avoiding the onerous complications
which might attend vigorous action. This ap-
proach to the problem, although less strenuous
to all concerned, does not serve the best in-
terests of the patients or advance the quality
of medical care.
Tissue, Medical Records, Credentials, and Ex-
ecutive Committees too frequently are plagued
by dissatisfaction with their actions. Grievance
Committees are highly labile sources of conten-
tion. With the advent of the Utilization Com-
mittees there has been presented to medical or-
ganizations another enigma in terms of the med-
ical-legal responsibility of the physicians who
sit on them. Unpopular decisions by such com-
45 —
SOUTH DAKOTA
mittees may invite litigation involving the com-
mittee as a whole or individually, the attending
physician, and the patient despite the fact that
the committee acted without malice and in good
faith, in accordance with by-laws, rules and
regulations.
In the event of lawsuit against officers or
committee members, despite the fact that the
suit may have little basis in fact, if the profes-
sional liability insurance of the individual, the
hospital, or the professional society, does not
cover such action, the cost of defense must be
borne by the physician himself. Not only is this
costly in terms of dollars and cents but in the
number of hours lost from practice, adverse
publicity, and psychological trauma. Legal pro-
tection for officers and committee members of
hospital staffs, medical societies and other medi-
cal organizations is becoming a subject of in-
creasing interest in this country today.
The avenues for legal protection open to phys-
icians in an executive or committee status of
hospitals or medical societies are threefold.
(1) Malpractice or professional liability insur-
ance which covers the situation. This can be on
an individual basis or a policy purchased by the
organization, or both. A physician in an execu-
tive or committee status of a hospital or medi-
cal society might wisely consult his insurance
agent or insurance company to determine if he
does, in fact, have the standardized form of Na-
tional Bureau of Casualty Underwriters cover-
age, or ask them to check the “insuring agree-
ment” to be certain it reads as follows:
Coverage A - Individual Coverage
Payment on behalf of the insured of all sums
which the insured shall become legally obli-
gated to pay as damages because of injury
arising out of
a. malpractice, error or mistake of the in-
sured or of a person for whose acts or
omissions the insured is legally respon-
sible except as a member of a partner-
ship, in rendering or failing to render pro-
fessional services, or
b. acts or omissions of the insured as a mem-
ber of a formal accreditation or similar
professional board or committee of a hos-
pital or professional society.
committed in the practice of the insured’s pro-
fession.
Exclusions under the policy should also be in-
spected to see that they read:
a. any use of X-ray apparatus for therapeu-
tic treatment;
b. liability of the insured as proprietor, su-
perintendent, or executive officer of any
hospital, sanitarium, clinic with bed and
board facilities, laboratory or business en-
terprise;
c. under Coverage B, such insurance as is or
can be afforded under Coverage A to any
member of a partnership (not applicable
when Coverage A only is provided);
d. Nuclear Energy Liability Exclusion
(broad form)
In some companies a broader coverage is given,
for “professional services rendered or which
should have been rendered” in place of the more
specific terms above.
(2) Incorporation of the medical society so as
to limit the individual liability.
(3) Legislative relief in the form of a law
which gives specific protection to persons in-
volved.
The California Legislature passed such a law
in 1963. (California Civil Code s43.7). More re-
cently a similar law was passed in South Da-
kota (CH. 151, 1966). The California law is as
follows:
There shall be no monetary liability on the
part of, and no cause of action for damages
shall arise against, any member of a duly ap-
pointed committee of a state or local profes-
sional society, or duly appointed member of
a committee of a medical staff of a licensed
hospital (provided the medical staff operates
pursuant to written bylaws that have been
approved by the governing board of the hos-
pital), for any act or proceeding undertaken
or performed within the scope of the func-
tions of any such committee which is formed
to maintain the professional standards of the
society established by its bylaws, if such
committee member acts without malice, has
made a reasonable effort to obtain the facts
of the matter as to which he acts, and acts
in reasonable belief that the action taken
by him is warranted by the facts known to
him after such reasonable effort to obtain
facts. “Professional society” includes legal,
medical, psychological, dental, accounting,
optometric, and engineering organizations
having as members at least a majority of
the eligible licentiates in the area served by
the particular society. The provisions of this
section do not affect the official immunity of
an officer or employee of a public corpora-
tion.
This section shall not be construed to con-
fer immunity from liability on any profes-
sional society or hospital. In any case in
which, but for the enactment of the preced-
ing provisions of this section, a cause of ac-
tion would arise against a hospital or pro-
fessional society, such cause of action shall
exist as if the preceding provisions of this
section had not been enacted.
In its original concept the California law was
introduced to raise professional standards with
resultant protection of the public. Its purpose
was to encourage review procedures which
would raise the quality of medical care, and
thereupon in the long run benefit sick people.
— 46 —
JUNE 1967
To date the laws have not been tested in the
courts of the states by which they were passed.
Until there is a test in the courts by the filing
of a lawsuit, they will provide a much needed
safeguard if committees are to be effective. It
may be anticipated that a court case would just-
ify the effect of the law.
COMMENTARY UPON THE LAW
BY THE ATTORNEY
Statutes such as that under consideration fall
into the general category of class legislation. As
such, they seem to have certain legally genetic
infirmity potential. The protective statute as it
stands is substantially all one sentence which,
at the outset, makes it a maze of semantics. It
has pitfalls, false walls, and traps in the floor.
It appears to say that money damages cannot
be collected, that no one can start a law suit
for damages against the various persons named,
and at first blush suggests a formidable protec-
tive wall. But like a breech delivery, sometimes
statutes are put together backwards.
The first portion of the law states that there
shall be no money damages given against the
indicated persons. Then the statute sets forth
a series of circumstances to be determined
which appear relatively limited in scope and
perhaps could be determined by a court as a
matter of law. But the remaining circumstances
appear clearly as questions for a jury. Thus,
legislation such as this does not prevent a phys-
ician from being sued in an individual capacity.
The first series of circumstances cover
“whether or not” situations: Is the physician a
“member” of a “duly appointed” “committee”
of a “state” or “local” “professional” “society”
or a “duly appointed” “member” of a “commit-
tee” of a “medical staff” of a “licensed hospi-
tal.” Each of the quoted words or phrases cov-
ers a rather limited yes or no situation. As ap-
plied to a “duly appointed member of a com-
mittee of a medical staff of a licensed hospital”
there is then the additional question of whether
the medical staff operates “pursuant to written
bylaws” which have “been approved by the gov-
erning board of the hospital.” This involves rel-
atively limited factual scope.
However, assuming the physician defendant
crosses all of these hurdles satisfactorily, he is
then faced with a broadening of determination
to have decided whether the act or proceeding
he undertook or performed was within the
“scope of the function of any such committee"
which is “formed to maintain” the “professional
standards of the society established by its by-
laws.” Matters such as this begin to rapidly di-
gress from simple yes or no situations. What is
the “scope” of such a committee; what are its
limitations; why was it formed; does it overlap
with any other committee? What professional
standards of the society were in fact established
by its bylaws? Here the physician may find the
bylaws of his society sadly lacking when viewed
with this type of legislation in mind.
Since the protection pertains to “professional
society,” how does one show that “at least a
majority” of the “eligible licentiates” are in-
cluded. And, what is the “area served” by the
particular society. These last requirements are
certainly not susceptible of simple proof, espec-
ially if there happens to be any dissension in
the ranks. If a physician or a group of phys-
icians are expelled from the organization be-
cause of mis-conduct, are they included in de-
termining the majority of eligible licentiates?
And, who determines the eligibility?
Perhaps it is specifically cogent to point out
that the thrust of this legislation is directed to-
ward an act or proceeding and makes no men-
tion of an omission. The statute gives protection
for acts done or proceedings taken if the bal-
ance of the conditions are met. There appears
to be no like protection if damage results from
the failure to act or proceed.
But again assuming the circumstances pass
legal scrutiny to this point, the lawyer is pre-
sented with a formidable task: The act done
must be without malice; there must be reason-
able effort to obtain facts; the physician must
act in reasonable belief on the facts. From the
wording of the statute, all three of these must
be shown to obtain the benefit of the protective
cloak.
The physician must have acted without mal-
ice; this term has legal technical significance
and involves a question of fact for a jury. It
must be shown that the physician has made a
reasonable effort to obtain facts, a jury question.
In addition, the physician must show that he
acted in reasonable belief that the action taken
by him was warranted by the facts. This is a
jury question. In litigation for monetary dam-
ages, the plaintiff characteristically exercises
his right to a trial by jury of fact questions. This
may be given to him by constitutional provi-
sions of his state or by the statutes of his state.
In most states the rules of procedure govern-
ing civil law suits provide for determination of
certain fact questions before trial by what is
called pre-trial discovery. Utilizing such proce-
dures the first “whether or not” facts probably
can be determined and agreed upon between
47 —
SOUTH DAKOTA
counsel for the parties and perhaps there could
even be a determination before trial of the
scope of function of a committee, the nature of
the professional standards and the effect of the
bylaws. But the group of circumstances involv-
ing “malice”, “reasonable effort”, “reasonable
belief”, fall into the technical arena of trial by
jury.
In an actual lawsuit, utilization of legislation
such as this by the defense at the pre-trial dis-
covery technically could result in dismissal of
the cause of action in a ruling by the court that
as a matter of law under the facts presented to
the court before trial there is no cause of ac-
tion for damages because all requirements of
the law have been met. However, it is doubtful
if there are many, if any, sets of circumstances
which would give this result.
Another unanswered question is that of who
has the burden of proof? Is it up to the phys-
ician to show that all of the requirements of
the statute have been met and he thereby gains
its protection, or is it up to the plaintiff to show
by his evidence that the protective require-
ments have not been met?
Since this is a type of class legislation the
defendant must plead the statute as what is
called an “affirmative defense.” That is, he
must say to the court that because of the ex-
istence of this statute he is entitled to its pro-
tection. It would appear that the burden is on
the physician to show that he has met the re-
quirements. In effect he says: Here is the stat-
ute and I have complied fully with it and, there-
fore, there can be no recovery of monetary li-
ability.
Is this type of legislation valid? The presump-
tion is in its favor as expression of public policy
by the legislature. Those who seek to invalidate
it have a heavy burden of proof. But good, bad,
or indifferent, the statute does not protect the
physician against being sued nor being required
to present in open court evidence that he has
met the statutory requirements and is entitled
to the legal shelter.
The person claiming damages is still entitled
to his day in court. We do not comment here
upon the advisability of jury trials except to
point out that where a constitutional right is de-
stroyed for one purpose, it is not reincarnated
for another.
SUMMARY
With the increasing complexity of medical
care and the problems attending executive com-
mittees, credentials committees, and utilization
committees of hospitals and local medical soci-
eties, some means to insure the protection of the
best interest of the patients is sorely needed.
Physicians in executive or potentially disciplin-
ary capacities must have a means of legal shel-
ter if they are to do the best job possible in the
impartial, conscientious, exercise of their office
in good faith, without fear of unjust reprisals.
This protection can be in the form of insurance,
incorporation of the society when applicable, or
by legislative relief. Laws have been passed by
the legislatures of two states but to date they
have not been tested in the courts. It is con-
ceivable that similar laws may be passed in
other states in the future.
The law as it stands in California and South
Dakota is not perfect but it is the best avail-
able and could help everybody. The law does
not protect the competent professional where he
is unable to operate with a medical staff because
of the nature of the community; where he
doesn’t have a hospital to operate in and there-
fore no bylaws. It doesn’t protect the man who
tries to raise the standards of the profession but
can’t meet the statutory requirements. This law
was originated in California where medicine
is highly organized. South Dakota is primarily
a rural state and the requisites of the law may
fail in the smaller hospitals. It eventually could
be reworked so as to improve the rough points.
Where it is available the physician should op-
erate under the law on the assumption that it
is an expression of policy by the legislature
(legislative intent) that will protect a man who
is trying to raise his professional standards in
an honest, careful, ethical manner.
— 48 —
Path CAPsule
Submitted by the College of American Pathology in
connection with the South Dakota Society of Pathol-
ogists.
URIC ACID
Uric acid is a purine compound found in hu-
man red cells and plasma, the concentration
in plasma being about twice that of the red
cells. Uric acid is the principal end-product of
purine metabolism in humans and apes, but
other mammals further oxidize the compound
to allantoin. There are three sources of the uric
acid found in human serum: ingested nucleo-
proteins (purine derivatives), degradation pro-
ducts of nucleoproteins in cellular material, and
synthesis from simple chemical precursors.
The site of uric acid synthesis in man is not
definitely known. It is formed from glycine, ni-
trogen from other amino acids, formate and
CO2. The bone marrow, liver and gastrointes-
tinal tract all have a high turnover of nucleo-
protein and are probable sites.
Uric acid is excreted chiefly in the urine in
the amount of 0.4-1. 0 gram daily1. This is de-
rived largely from both the exogenous variety
originating from nucleins of food and the en-
dogenous variety produced by metabolic de-
struction of nuclei of the body. It is excreted in
the form of sodium and potassium urates and as
uric acid. In concentrated urines amorphous
urates and crystals of uric acid may be found.
These are normal components and are not to be
considered evidence of increased uric acid ex-
cretion.
NORMAL VALUES:
Adult males 3.5 to 6.0 (average
5.1) mg per 100 ml.
Adult females 2.9 to 5.0 (average
4.1) mg per 100 ml.
Children up to puberty 2.1 to 3.9 (average
3.3) mg per 100 ml.
LOW VALUES have no clinical significance, and may
be found after administration of A.C.T.H. and
uricosuric drugs (which include aspirin).
HIGH VALUES are found in any condition where
there is either a decreased excretion, an in-
creased production, or a decreased destruction of
uric acid. Some of these conditions are:
1. Gout is the most common disorder of pu-
rine metabolism. Only 2% of gouty patients
have serum uric acid values below 6.0 mg%.
Serial determinations are sometimes necessary
to establish a diagnosis. A diagnosis of gout
should not be made solely on the basis of a lab-
oratory determination, without other evidence
such as physical findings and family history.
While it is true that a high uric acid value is
almost always a constant finding in gout, all
patients with moderate elevations above 6.0
mg% do not have this disease. Currently, the
significance of increased values in these patients
is not clear and it is well to follow such individ-
uals with repeated uric acid determinations.
Urate crystals may be deposited about joints
and in kidney parenchyma producing renal in-
sufficiency. It is not known if high uric acid
values found in these patients are due to defici-
ent elimination or increased production of uric
acid. Apparently there are two types of gouty
patients, those with an abnormally high basal
uric acid excretion and those with a normal ex-
cretion. There is some evidence that there may
be increased production in the former group.
2. Relaiives of patients with gout frequently
have asymptomatic high serum uric acid values.
This is apparently on the basis of a genetically
inherited characteristic.
3. Excessive destruction of nuclear material
which occurs in leukemia, polycythemia, star-
vation, resolving pneumonia and toxemias of
pregnancy frequently cause high uric acid val-
ues. Serial uric acid analyses are of value in
estimating prognosis in toxemias of pregnancy.
A steady and progressive rise is one of the in-
dications for interrupting the pregnancy.
4. Kidney dysfunction of various types causes
high uric acid values because of decreased elim-
ination. There is no uniform correlation, how-
ever, between the serum concentration and the
severity of kidney damage. Consequently, uric
acid determinations should not be used for
estimating the extent of renal impairment. The
retention of urea and creatinine appear earlier,
are more marked and are of greater value in
diagnosis and prognosis.2
5. Other High Values: A dilemma, which con-
fronts the physician and which is seen all too
frequently, is the high uric acid value in pa-
tients who appear to be well. As previously
stated, an elevated value does not make a di-
agnosis of gout mandatory. It is seen as a trans-
itory finding in patients who have ingested
large amounts of nucleoproteins that are present
in liver or sweetbreads. Patients, particularly
if obese, who are on high protein diets for
weight reduction may show quite high values.
Renal disease, blood dyscrasias, medication of
various sorts and coffee consumption in the
hours preceding the test can be related to high
values. A substantial number of abnormal val-
ues, however, remain unexplained.
(Continued on Page 52)
— 49
50
S.D.J.O.M. JUNE 1967 - ADV.
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•j
1907 — 60TH A N N I V E RS ARY Y E AR— 1 967
COMMENTARY
From
THE UNIVERSITY OF SOUTH DAKOTA SCHOOL OF MEDICINE
Edited by: Dr. Charles R. Gaush, Publications Committee
MEDICAL SCHOOL DINNER DANCE
The annual Medical School Dinner Dance,
sponsored by the SAMA, was held at the Sher-
aton-Cataract Hotel in Sioux Falls on April 8.
The featured speaker was Dr. John H. Law-
rence, Director of the Donner Laboratory at the
University of California, who spoke on “Present
Examples and Future Possibilities of Nuclear
Medicine in Research, Diagnosis and Therapy.”
Prior to Dr. Lawrence’s presentation, more
than $7,300 in prizes, scholarships and awards
were given to freshman and sophomore students
as well as incoming freshman students. The re-
cipients of these awards were:
Norman Neu:
Charles Pfizer Award
Lang Book Award
Wesley Putnam:
Huron Clinic Award
Shaw Medical Student Award
Lang Book Award
Gerald Evans:
Nakao Scholarship
Terrence Pfeiffer:
Nakao Scholarship
David Johnson:
Avalon Foundation Scholarship
Harold Adams:
Avalon Foundation Scholarship
Curtis Mark:
State Medical Association Award
Douglas Stauch:
Yankton Clinic Award
James Reynolds:
Payne Scholarship
Huron Clinic Scholarship
Hoffman-LaRoche Award
William Hanking:
Payne Scholarship
Medical Faculty Award
Mosby Book Award
George C. Roth:
Christian P. Lommen Award
Kreiser Medical Scholarship
Mosby Book Award
Walter K. Sosey:
Wm. E. Edwards Award
Arnold Pritchow Award
Mosby Book Award
Robert W. Block:
J. A. Kittelson Award
Meisenholder Award
Mosby Book Award
Charles L. Parks:
Yankton Clinic Award
Kreiser Memorial Award
Mosby Book Award
Rodney Parry:
South Dakota Medical Assoc. Award
Lang Book Award
Leon Schwartz:
Eldridge Memorial Award
Raymond Townsend:
WA-SAMA Award
Henry J. Fee:
Lang Book Award
John Carter:
Merck Award
Jerald Bratberg:
Price Award in Anatomy
AWARDS TO INCOMING FRESHMEN:
Marie C. Dunn:
Avalon Foundation Scholarship
Michael Scarmone:
South Dakota Medical Assoc. Scholarship
Martin Hanneman:
Lyle J. Hare Scholarship
Several members of the faculty were also
recognized at the award ceremonies. Drs. Karl
H. Wegner and John F. Barlow were given the
Distinguished Professor Award for exemplary
teaching. Drs. Joseph D. Welty and Finley D.
Marshall received the Brookings Clinic Award
for outstanding service to the Medical School.
Also recognized for their services to the Medi-
cal School were Drs. George W. Knabe, Jr.,
Warren L. Jones and Mr. Earl F. Bihlmeyer.
PHOTO CONTEST WINNER
We have just been informed that Mr. Carroll
D. Isburg, freshman medical student from
Yankton, won 2nd prize for photomicrography
in the 9th Annual Medical Art Competition. This
competition is sponsored by the SAMA and
Eaton Laboratories, Division of Norwich Phar-
macal Company for outstanding work in medi-
cal photography, photomicrography and medical
illustration.
Mr. Isburg’s entry was a color photograph of
human erythrocytes stained by the indirect
fluorescent antibody technique and was taken
on Kodak High Speed Ektachrome film with a
51 —
SOUTH DAKOTA
Leitz-SM Fluorescence Microscope. Second
prize for photomicrography in this national
competition was a $150 award and a trophy.
DR. CRITZ LEAVES USD
Dr. Jerry B. Critz resigned his position as
Associate Professor of Physiology and Pharma-
cology to accept an appointment as Associate
Professor of Physiology at the University of
Western Ontario School of Medicine. Dr. Critz,
who received his Ph.D. from the University of
Missouri, joined our staff in 1961 and carried
out research on serum enzymes and their role
in cardiovascular incompetence.
TOCAR SWIM-TRAINER
A new product of interest to parents is the
Tocar Swim-Trainer which makes it possible
for anyone to train babies and small children to
swim. The Swim-Trainer is so simple that any-
one — even a non-swimmer — who can follow
simple instructions can train a baby to swim.
The Swim-Trainer is constructed of detach-
able molded blocks of expanded, flecked, white
polystyrene. The blocks are strapped together
to form a unit measuring approximately 9” x 6”
x 4”. One block has a web or plastic strap at-
tached for fastening the unit to the child’s back.
The instructor progressively removes individ-
ual blocks from the Swim-Trainer during a
series of training sessions. The child learns to
compensate for the gradually decreasing flota-
tion. When all blocks are eventually removed,
the child can swim independently.
The Swim-Trainer complete with instructions
costs $3.50 each postpaid. Tocar, Inc., P. O. Box
55309, Houston, Texas 77055.
MEDICAL TOUR
A matter which may be of interest to South
Dakota physicians is an official tour sponsored
by the Ministry of Health of the U.S.S.R., in
connection with the 2nd International Sympo-
sium on Medical Treatment in Spas and Physio-
therapy. Participation is open to all members of
the medical profession, regardless of their spe-
cialty.
The tour is scheduled to leave New York on
Wednesday, August 30th and return to New
York on Monday, September 18th. The tour rate
is $865 per person, which includes such items
as air transportation (in cooperation with Pan
American World Airways), hotel accommoda-
tions, meals, transfers, sightseeing, baggage al-
lowance, service & taxes. The $10 registration
fee for the Symposium is not included, nor is
the cost of passport, visa fees and processing.
A deposit of $100 per person is required on
travel arrangements at time of registration.
Further details and a brochure may be obtained
by writing Compass Travel Bureau, Inc., 55
West 42nd Street, New York, New York 10036.
(Continued from Page 49)
Indications for the Test: The level of the se-
rum uric acid should be determined whenever
gout is suspected. In toxemias of pregnancy re-
peated determinations aid in following therapy
and in estimating prognosis.
Material needed for the Test: Serum 3 ml.
REFERENCES
1. Davidsohn & Wells, Clinical Diagnosis by Labora-
tory Methods, 13th Edition, p. 28.
2. Miller, A textbook of Clinical Pathology, 6th Edi-
tion, p. 246.
- - - but the person who’s convalescing or is
handicapped will find new freedom from the
extra comfort and smooth, easy operation of
this marvelous Everest & Jennings wheelchair.
Elmen Rent- All offers you just about every-
thing to help patients get well faster. The first
month’s rent applies to the purchase price.
We hope you never need such things, but if you
do, we’re at your service 24 hours a day.
Send for your free Medicare Catalog.
ELMEN RENT-ALL
Sioux Falls Rapid City
1701 West 12th Street 325 West Boulevard
336-3670
— 52
A NEW ROLE FOR BLUE SHIELD
Physicians are looking to Blue Shield to fill
a new role.
Title 18 of Medicare covers some 20 million
people. Title 19 will eventually cover another
35 million. Millions more are, or will be, cov-
ered under various other government programs.
It has been estimated that by 1975, more than
25 percent of Americans will have their health
care covered by some form of governmental
program.
H. Russell Brown, M.D., chairman of the AMA
committee on insurance and prepayment, has
said that medical associations must recognize
that the federal government is now becoming
a massive third party payer in the medical care
field.
“This insurer,” he said, “is in a tax-supported
position in competition with all other insuring
organizations. Therefore, individually and col-
lectively we must carry on negotiations regard-
ing financial as well as other relationships with
government either directly or indirectly.”
Reprinted with permission from The Blue Shield, Vol.
3, No. 4, April, 1966.
He went on to say: “Rather than to deal (with
the government) directly and segmentally by
county and state medical societies, it would ap-
pear far better to utilize our companion organi-
zation — Blue Shield — as a buffer between
government and the physician. Thus the techni-
cal personnel and knowledge of the Blue Shield
organization in this field can be utilized to
carry on negotiations, to perfect procedures, and
to serve as contractor and administrator.
“If this new role for Blue Shield is to be ac-
complished, physicians and medical societies
must actively promote and develop closer re-
lationships with the Plans they sponsor.”
It is imperative, he continued, that, at this
point in time, conflicts between individual phys-
icians and/or medical societies and Blue Shield
must be resolved. He indicated that medical
societies at all levels should consider seriously
taking positive action to request Blue Shield to
assume the role of a negotiator between them
and government.
It is a difficult road, a treacherous road for
Blue Shield to negotiate. Yet, Blue Shield will-
ingly accepts this difficult assignment as its
contribution to preserving the free practice of
medicine.
— 53 —
ZetterA to the £ 4 iter
University of South Dakota
School of Medicine
March 31, 1967
Mr. Richard C. Erickson, Ex. Sec.
S. D. State Medical Association
711 North Lake Avenue
Sioux Falls, South Dakota 57104
Dear Mr. Erickson:
Within the last week, it has come to the at-
tention of our SAMA Chapter that the Council
of the State Medical Association, in addition to
renewing its three annual scholarships, has
awarded $200.00 to be directed toward defray-
ing the expenses of our student delegates who
will attend the National SAMA Convention in
Chicago this coming May. Please express our
thanks to the Council for this financial help;
we really appreciate this gesture of the State
Association’s continuing interest in our SAMA
Chapter.
Sincerely,
Sandra Jassmann, Secretary
Student American Medical Association
SJ./da
University of South Dakota
School of Medicine
April 17, 1967
Richard Erickson
South Dakota Medical Association
711 North Lake Avenue
Sioux Falls, South Dakota 57104
Dear Dick:
Received your letter of April 11, 1967, with
the lovely check for $5,061.94 representing the
USD Medical School share in AMA-ERF con-
tributions for 1966. As you well know this an-
nual contribution has considerable significance
in the operation of this medical school. We will
of course acknowledge this check to Dr. Blas-
ingame, but we thought it also appropriate to
thank our local medical association representa-
tives. I trust you will convey this feeling of ap-
preciation whenever the occasion may arise.
Sincerely yours,
Earl F. Bihlmeyer
Administrative Assistant
EFB/dl
Mrs. Schlosser
South Dakota State Medical Association
711 North Lake
Sioux Falls, South Dakota
Dear Mrs. Schlosser:
During the past year, perhaps you have noted
that there have been included as a more-or-less
regular feature Clinical Pathological Confer-
ences from Sioux Valley Hospital. We who are
writing these articles would like to know from
the practicing physicians of the state whether
these are considered worthwhile as a continu-
ing feature and whether they are of any prac-
tical value. Your comments will be appreciated.
Sincerely,
J. F. Barlow, M.D.
Pathologist
Mr. Richard C. Erickson
Executive Secretary
South Dakota State Medical Association
711 North Lake Avenue
Sioux Falls, South Dakota
Dear Mr. Erickson:
The award established by the State Medical
Association and given to me at the Medical
School dinner is greatly appreciated as is the
interest displayed by the South Dakota phys-
icians in their medical students.
At the present time I am enjoying an excel-
lent educational experience in Aberdeen.
Thank you very much.
Sincerely yours,
Rod Parry
Richard C. Erickson, Executive Secretary
South Dakota State Medical Association
711 North Lake Avenue
Sioux Falls, South Dakota
Dear Mr. Erickson:
I wish to thank you for the State Medical As-
sociation scholarship. You are no doubt well
aware of the high cost of a medical education
and thus you are able to understand my appre-
ciation of the award.
Sincerely,
Curtis L. Mark
Freshman Medical Student
Vermillion, South Dakota
— 54 —
JUNE 1967
ANNOUNCEMENTS
An intensive training program in Cardiology
is offered by the full time staff of the Institute
for Cardiovascular Disease, Good Samaritan
Hospital, Phoenix, Arizona. This is an intensive
academic effort covering the U.S.A. and abroad.
The fellows will be trained specifically in the
areas of: clinical care, intensive coronary care
unit, electrocardiography, vectorcardiography,
phonocardiography, apex cardiography, cardi-
ovascular pathology, cardiovascular surgery,
cardiac catheterization, selective angiography
and clinical investigation. Experimental cardio-
vascular physiology, medical electronics, and
statistics are also part of the program on an
elective basis.
Stipend — $7,000.00.
For information write: A. Benchimol, M.D.,
Director, Institute for Cardiovascular Diseases,
Good Samaritan Hospital, 1033 East McDowell
Road, Phoenix, Arizona 85002.
“Basic and Clinical Aspects of Therapy in Ad-
vanced Cancer,” October 16-21, 1967. University
of Wisconsin Medical Center. The purpose of
this course is to demonstrate the practical clin-
ical application of laboratory science discover-
ies in anti-cancer therapy. For further informa-
tion on the course, contact R. J. Samp, M.D.,
Cancer Program Coordinator, University Hos-
pitals, Madison, Wisconsin 53706.
'Doom- Boo H ! Boon- boom!
Boom ! — w
Dr. Irving S. Wright (right), president of the Amer-
ican College of Physicians, and Howard W. Baldock,
director of medical relations for Squibb, are shown
at the exhibit.
A collection of twenty original oil paintings
of the oldest medical colleges of America was
on view during the recent annual meeting of
the American College of Physicians in San Fran-
cisco. They represent the first of a growing col-
lection that is part of the “Collegia Medica”
program established in 1965 by E. R. Squibb &
Sons, Inc.
The “Collegia Medica” program is a long-
range plan to create a collection of original
paintings of the medical colleges of America.
Two paintings of each college are rendered by
an outstanding artist chosen, whenever possible,
from the area in which each school is located.
One is presented to the dean for permanent dis-
play at the institution. The other becomes part
of a Squibb collection to be displayed periodic-
ally throughout the United States.
The program will continue until representa-
tive paintings of each medical school have been
completed. There are, at present, 86 accredited,
four-year schools of medicine in the United
States.
Symposia on Iron Storage, Colitis, Among
Scientific Programs at AMA Annual Convention
Symposia of interest to both the generalist
and the specialist will be included in this year’s
Scientific Program of the American Medical
Association’s Annual Convention.
The Convention will be held in Atlantic City
June 18-22, the Scientific Program in Conven-
tion Hall and surrounding hotels and the House
of Delegates at the Chalfonte-Haddon Hall Ho-
tel.
A Symposium on Absorption and Storage of
Iron will be presented as a joint meeting of
— 55 —
SOUTH DAKOTA
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(Warning: may be habit forming)
BENSULFOID® (See PDR) .65 mg.
Precaution: same as 16 mg. of phenobarbital
Constructive Therapy
A Solfoton tablet or capsule at 6 hour intervals
maintains sedation at the threshold of calmness,
sustaining a mental climate for purposeful living.
Literature and clinical samples sent upon request.
FEDERAL LAW PROHIBITS DISPENSING
WITHOUT PRESCRIPTION
AVAILABLE
Solfoton ( yellow , uncoated tablets “ P ”)
100s, 500s, 5000s
Solfoton Capsules (yellow and brown)
100s, 500s, 1000s
Solfoton S/C ( sugar-coated beige tablets )
100s, 500s, 4000s
WM. P. POYTHRESS & CO., INC.
RICHMOND, VIRGINIA 23217
Manufacturers of ethical pharmaceuticals since 1856
the Sections on Pathology and Physiology, In-
ternal Medicine, Experimental Medicine and
Therapeutics, and Gastroenterology.
The Sections on Radiology, Proctology, Pedi-
atrics, General Surgery, Internal Medicine, and
Gastroenterology will join for a Symposium on
Granulomatous Colitis and Ulcerative Colitis
in Children.
Other symposia are being planned and sched-
uled.
The entire Scientific Program for the 1967
Annual Convention was published in the May 8
issue of the Journal of the American Medical
Association.
THE MONTH IN WASHINGTON
The American Medical Association proposed
that Congress set up a National Commission on
Health Resources and Medical Manpower with
broad powers to supervise the drafting of phys-
icians for military service.
The AMA recommendation was presented by
Dr. Albert H. Schwichtenberg, chairman of the
AMA Council on National Security, at a Senate
Armed Services Committee hearing on S. 1432
which would provide for a four-year extension
of the present draft law expiring June 30.
Other AMA recommendations for modifica-
tion of the doctor draft program included:
— Expansion of the physician draft pool to in-
clude women doctors.
— Making subject to draft call foreign phys-
icians under 35 years of age, with permanent
visas or who have subsequently become citizens,
and who may not be subject to call because they
were not deferred from induction while under
age 26.
— Limiting credit for fulfillment of the draft
obligation to only service performed in the
armed services. (Under the old law, service in
the Public Health Service could satisfy a phys-
ician’s obligation for active military duty.)
— Routine transfer, upon completion of an in-
ternship, of the jurisdiction of physicians to the
local draft board serving the area in which the
physician is engaged in training or practice.
— Changes in the pay and promotion policies
for military physicians designed to increase the
retention of career military physicians.
“Our primary recommendation ... is the cre-
ation of a National Commission on Health Re-
sources and Medical Manpower,” Dr. Schwich-
tenberg said. “This Commission would replace
and be responsible for the functions of the pres-
ent National Advisory Committee and the
Health Resources Advisory Committee. This
— 56 —
JUNE 1 967
new Commission, under the direction of the
President, would have the responsibility of
maintaining a proper balance of health person-
nel, within existing resources, among the Armed
Forces, other Government agencies, and the
civilian population. Requests of the Secretary
of Defense for health manpower in the military
would be reviewed and approved by the Com-
mission. The Commission would establish for
the Selective Service System criteria for classi-
fying, reclassifying and determining the order
of selection for health personnel. Under this pro-
posal, the present State Advisory Committees
would be redesignated as State Health Man-
power Committees, whose activities would be
coordinated by the National Commission. It is
further recommended that the Commission
should be constituted from among persons of
outstanding national reputation in the health-
care fields, and its composition should include
substantial representation from physicians in
private practice.”
^ ^
The National Highway Agency announced
tentative standards for emergency medical serv-
ices provided for persons injured in traffic ac-
cidents.
The federal standards give the states broad
authority in implementation and also are sub-
ject to comment by the states before they be-
come final. The state programs must be in full
operation before Jan. 1, 1969, or a state could
lose up to 10 percent of its allotted federal high-
way construction funds.
Although the federal standards apply only to
traffic accidents, they are expected to necessar-
ily set a pattern for emergency medical serv-
ices generally.
Dr. William Haddon, Jr., head of the National
Highway Safety Agency, said the emergency
care regulations are designed to provide quick
response to accidents, sustain and prolong life
through proper first aid measures, reduce the
likelihood of permanent disability and pro-
longed hospitalization, and provide speedy
transportation of accident victims to hospitals.
The federal standards would require states
to:
— Appoint a full-time medical emergency
services coordinator to have primary responsi-
bility for the program.
— Prepare a comprehensive plan for emer-
gency services throughout the state.
— Establish training, licensing and related re-
quirements for ambulance drivers, attendants,
and dispatchers.
EMPHYSEMA
• ASTHMA
• CHRONIC BRONCHITIS
• BRONCHIECTASIS
Each tablet contains:
Potassium Iodide 195 mg.
Aminophylline 130 mg.
Phenobarbital, Caution: May be habit forming. . . 21 mg.
Ephedrine HC1 16 mg.
FEDERAL LAW PROHIBITS
DISPENSING WITHOUT PRESCRIPTION
Precautions: Usual for aminophylline-ephedrine-
phenobarbital. Iodides may cause nausea, long use
may cause goiter. Discontinue if symptoms of
iodism develop.
Iodide contraindications: tuberculosis, pregnancy.
DOSAGE
One tablet, with full glass of
water, 3 or 4 times daily.
Dispensed in bottles of 100 and 1000 tablets.
MUDRANE GG — Formula, dosage and package identi-
cal to Mudrane — except — 100 mg. glyceryl guaiacolate
replaces the potassium iodide. The value of Mudrane
cannot be enjoyed by a small group in which K.I. is
contraindicated. Mudrane GG is prepared lor this group.
MUDRANE GG ELIXIR — Four 5 cc teaspoonfuls is
equivalent to one Mudrane GG tablet. Dosage adjusted
to age and weight of child. Mudrane GG Elixir is for
pediatric patients and those who think they cannot swal-
low tablets. Dispensed in pint and half gallon bottles.
WM. P. POYTHRESS & CO., INC.
RICHMOND, VIRGINIA 23217
Manufacturers of ethical pharmaceuticals since 1856
— 57 —
SOUTH DAKOTA
— Coordinate ambulance and other emergency
medical care systems, including requiring am-
bulances to carry two-way radios hooked up
with the police and hospitals.
— Provide first aid training and refresher
courses for emergency service personnel and po-
licemen and firemen, and encourage first aid
instruction for the public.
Other draft regulations with medical aspects:
— Make physical and eyesight examinations
for driver licensing.
— Do compulsory blood tests for alcohol on
drivers in accidents.
^ ^ $
Dr. John C. Nunemaker, chairman of the
American Medical Association’s Department of
Graduate Medical Education, told a House Ju-
diciary Subcommittee that the AMA’s position
continues to be that graduates of foreign medi-
cal schools who come to the United States for
training “should be encouraged in every pos-
sible way to return to their home countries
where their skills are so badly needed.”
Dr. Nunemaker suggested that the five-year
length of stay provision for physicians on ex-
change programs be reconsidered. Every year
beyond two or three years “intensifies the de-
sire of the visitor to stay longer,” he noted.
standard and custom
EVEREST t JENNINGS
FOLDING
WHEEL
CHAIRS
ALSO
nn WALKERS
Jra&Hl CRUTCHES
/rTtjlii RATtWT UFTS
MJ "1 ^ COMMODES
1 |
Rentals * Sales
Kreiser Surgical, Inc.
Sioux Fails Rapid City
‘COCA-COLA" AND "COKE" ARE REGISTERED TRADE-MARKS WHICH IDENTIFY ONLY THE PRODUCT OF THE COCA-COLA COMPANY.
For the taste
you never
get tired of.
wmm
— 58 —
7kti U IjCUh
MEDICAL ASSOCIATION
News Notes • Changes • Births • News
Pop's Proverb
A word of encouragement
is often worth more than
financial help.
Samuel Rosa, M.D. of the
Redfield State Hospital and
School recently spoke on re-
search in mental retardation
at the Spink County Associa-
tion of Retarded Children.
H5 ^ ^
A news story from Lawr-
enceville, Georgia, about the
progress being made in find-
ing better vaccines to treat
rabies involved two South Da-
kotans. The story mentioned
that the only reported fatal
case of rabies in the United
States in 1966 concerned a
South Dakota boy (who died
in Sioux Falls). (This case was
presented in the May issue of
the Journal.)
The news story mentioned
the research of Dr. R. E.
Dierks of the U. S. Public
Health Service. He is former-
ly of Flandreau, and is mar-
ried to the former Carol Am-
undson of Colton, a sister of
Dr. Loren Amundson of Sioux
Falls.
James Daggett, M.D. will
establish a medical practice in
Lennox, South Dakota begin-
ning July 1st.
Doctor Daggett is presently
concluding his internship at
Sioux Valley Hospital in
Sioux Falls. He will be associ-
ated with the Donahoe Clinic
in Sioux Falls, but will prac-
tice in Lennox on a full-time
basis.
Doctor and Mrs. Daggett
have three children, and are
presently residing in Sioux
Falls, but plan to make their
home in Lennox soon.
YOUR
CONTRIBUTION
TO THE
SOUTH DAKOTA
MEDICAL SCHOOL
ENDOWMENT
FUND
IS NEEDED
Guest speaker at the April
meeting of the Black Hills
Medical Society was Harry H.
LeVeen, M.D., Chief of Sur-
gical Service, Veterans Ad-
ministration Hospital, Brook-
lyn, New York. He is also Pro-
fessor of Surgery at the Down
State Medical Center, State
University of New York.
Doctor LeVeen’s topic was
“Surgical Intensive Care Prob-
lems.” Following the lecture,
time was devoted to questions
and a critique on Dr. Le-
Veen’s discussion by Merle M.
Musselman, M.D., Surgical
Consultant for the Veterans
Administration Center.
^
An opinion requested by the
state’s attorney for Potter
County on whether or not a
municipality can spend pub-
lic funds to buy a doctor’s
clinic has been given by At-
torney General Frank Farrar.
According to the Attorney
General, the city can neither
purchase the clinic using pub-
lic funds nor accept the clinic
as a gift.
The city of Hoven was con-
sidering buying a clinic owned
by a private non-profit cor-
poration with liquor store
funds.
— 59 —
SOUTH DAKOTA
David J. Buchanan, M.D.
gave the commencement ad-
dress at Letcher, South Da-
kota, on May 10, 1967.
❖ ❖ ❖
Eduardo G. Francisco, M.D.,
Estelline, has been elected to
active membership in the Am-
erican Academy of General
Practice.
% sH
Francis P. Kwan, M.D.,
Rapid City pediatrician, was
elected to fellowship in the
American Academy of Pedi-
atrics at its recent spring ses-
sion in San Francisco.
Doctor Kwan took his M.D.
at Marquette Medical School
in 1957, and interned at St.
Joseph’s Hospital in Milwau-
kee, Wisconsin. He served for
two years as director of the
Bureau of Preventable Dis-
eases and Medical Services at
Milwaukee.
His residency in pediatrics
was taken at Milwaukee
Children’s Hospital. He has
been associated with the Rap-
id City Medical Center since
July of 1962.
The second annual meeting
of the Society for Cryo-Oph-
thalmology will be held in Mi-
ami Beach, January 14 to 18,
1968, with Dr. Jose Barraquer,
of Bogota, Colombia, presid-
ing. The program will include
a session on retinal surgery,
with Dr. Giambattista, of
Rome, as the featured speaker.
Dr. H. Fanta, of Vienna, will
lead the discussion on cryoex-
traction of cataracts.
Those wishing to present
papers at this meeting should
submit title and brief abstract
to Dr. John G. Bellows, execu-
tive secretary, 30 N. Michigan
Ave., Chicago, Illinois, 60602,
at the earliest possible date.
^ H5 ❖
Three members of the Sioux
Falls Board of Education at-
tended the convention of the
National School Boards As-
sociation in Portland, Oregon.
Roy Knowles, M.D. was the
main speaker at one of 62 spe-
cial interest clinics. He spoke
to wives of school board mem-
bers about their relationship
with their communities.
Also in attendance were
board president, Rev. Selmer
Heen, and Dr. Paul Reagan.
The Tenth Annual Post-
graduate Course in Pediatrics
will be offered July 31
through August 4, 1967 at the
Stanley Hotel, Estes Park,
Colorado. The tuition fee for
the five-day course is $80.00,
including a registration fee of
$10.00 which is non-refund-
able. Detailed information on
housing accommodations will
be sent upon receipt of appli-
cation or upon request. Fur-
ther information may be ob-
tained from The Office of
Postgraduate Medical Educa-
tion, University of Colorado
School of Medicine, 4200 East
Ninth Avenue, Denver, Col-
orado 80220.
— 60 —
r»c vu-t*n LIOttAWY
UNIVERSITY OF MARYLAN*
circulates after.
H DAKOTA
Among the adjuncts to the physician’s skill
Darvon® Compound- 65
Each Pulvule® contains 65 mg. propoxyphene hydrochloride,
227 mg. aspirin, 162 mg. phenacetin, and 32.4 mg. caffeine.
Skey
Additional information available to the medical profession upon request.
ELI LILLY AND COMPANY, INDIANAPOLIS, INDIANA 46206
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whate
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for control of
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some allergens are green
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PRECAUTIONS: Persons who have become drowsy
on this or other antihistamine-containing drugs, or
whose tolerance is not known, should not drive
vehicles or engage in other activities requiring keen
response while using this product. Hypnotics, sed-
atives, or tranquilizers if used with diphenhydramine
hydrochloride should be prescribed with caution
because of possible additive effect. Diphenhydramine
The pink capsule with the white band is a trademark
of Parke, Davis & Company.
has an atropine-like action which should be con-
sidered when prescribing diphenhydramine hydro-
chloride. ADVERSE REACTIONS: Side effects are
generally mild and may affect the nervous, gastro-
intestinal, and cardiovascular systems. Drowsiness,
dizziness, dryness of the mouth, nausea, nervousness,
palpitation, blurring of vision, vertigo, headache,
muscular aching, thickening of bronchial secretions,
restlessness, and insomnia have been reported.
Allergic reactions may occur.
BENADRYL is available in Kapseals® of 50 mg. and
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BSP, one of the more valuable single
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hepatic function, is now packaged in a
complete individual patient-unit.
Each BSP Disposable Unit contains a
sterile syringe with the 5 mg./ kg. BSP
dosage schedule imprinted on the barrel,
a sterile needle, alcohol swab and a 7.5 ml.
or 10 ml. size ampule of terminally
sterilized Bromsulphalein solution.
This all-inclusive disposable put-up
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HYNSON, WESTCOTT & DUNNING, INC.
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— ■ —
it
1- Is
z-m
—
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
Volume XX July, 1967 Number 7
CONTENTS
Professional Liability — Its Basis and Defense 15
W. A. Mossberg
Medical Malpractice — What It Is and How to Avoid It 23
Roger F. Johnson, M.D., LL.B.
Malpractice Claims 30
Dan Hoffman
Abstracts on Tuberculosis and Other Respiratory Diseases 39
What Constitutes the Diagnosis of Thyroiditis? 49
Cedric B. Fortune, M.D.
Ethike, Caduceus; Aesculapius 53
David Goldblatt
PathCAPsule 58
Commentary 67
Editorials 71
Letters 74
President’s Page 75
This Is Your Medical Association 77
Second Class Postage Paid at Sioux Falls, South Dakota
Published monthly by the South Dakota Medical Association, Publication Office
711 North Lake Avenue, Sioux Falls, South Dakota 57104
S.D.J.O.M. JULY 1967 - ADV.
3
CONTAINS A BALANCED
COMBINATION
OF THE MOST WIDELY
USED ANTACIDS—
FOR RAPID
NEUTRALIZATION.
PLUS SIMETHICONE—
TO CONTROL
THE FACTOR WHICH
ANTACIDS ALONE
CANNOT INFLUENCE.
■ In Mylanta, aluminum and magnesium hydroxides are
balanced to minimize the chance of constipation or laxation
and still achieve rapid acid neutralization and pain relief.
■ The positive action of simethicone helps relieve the pain-
ful gas symptoms which often accompany the peptic ulcer
syndrome.
■ The nonfatiguing flavor and smooth, nongritty consistency
of tablets and liquid encourage continued patient coopera-
tion during long-term therapy.
Composition: Each Mylanta chewable tablet or teaspoonful (5 ml.)
of liquid contains: magnesium hydroxide. 200 mg.; aluminum hydrox-
ide, dried gel, 200 mg.; simethicone, 20 mg. Dosage: one or two tab-
lets, well chewed or allowed to dissolve in the mouth, or one or two
teaspoonfuls of liquid to be taken between meals and at bedtime.
The Stuart Company, Pasadena, California
Division of Atlas Chemical Industries, Inc.
THE SOUTH DAKOTA
JOURNAL OF MEDICINE
JOURNAL OF THE SOUTH DAKOTA STATE MEDICAL ASSOCIATION
AND THE SIOUX VALLEY MEDICAL ASSOCIATION
SUBSCRIPTION $2.00 PER YEAR
SINGLE COPY 20c
Volume XX
July, 1967
Number 7
Editor
Assistant Editor ..
Associate Editor ..
Associate Editor ..
Associate Editor ..
Business Manager
STAFF
Robert Van Demark, M.D.
Judith Perkins Schlosser ..
Robert Thompson, M.D
Gordon Paulson, M.D
Gerald Tracy, M.D
Richard C. Erickson
.... Sioux
Falls,
S.
D.
.... Sioux
Falls,
S.
D.
Yankton,
S.
D.
..... Rapid
City,
S.
D.
Watertown,
S.
D.
... Sioux
Falls,
S.
D.
EDITORIAL COMMITTEE
R. E. Van Demark, M.D., Chr.
J. A. Anderson, M.D.
G. E. Tracy, M.D
W. R. J. Kilpatrick, M.D
Hugo Andre, M.D
H. B. Munson, M.D.
R. F. Thompson, M.D.
John B. Gregg, M.D.
Sioux Falls, S. D.
_ Madison, S. D.
Watertown, S. D.
Huron, S. D.
Vermillion, S. D.
Rapid City, S. D.
... Yankton, S. D.
Sioux Falls, S. D.
PUBLICATIONS COMMITTEE
R. E. Van Demark, M.D., Gordon Paulson, M.D., Robert Thompson, M.D., W. T. Sweeney,
M.D.
OFFICERS
South Dakota Slate Medical Association
President
President-Elect
Vice-President
Secretary-Treasurer
Executive Secretary
Delegate to A.M.A.
Alternate Delegate to A.M.A.
Chairman Council
Speaker of The House
-P. Preston Brogdon, M.D
..John Stransky, M.D.
...J. T. Elston, M.D
-A. P. Reding, M.D.
...Richard C. Erickson
-A. P. Reding, M.D.
-R. H. Quinn, M.D.
...E. T. Lietzke, M.D
...J. P. Steele, M.D
Sioux Valley Medical Association
President C. J. McDonald, M.D
Secretary Daniel Youngblade, M.D.
Treasurer Karl Wegner, M.D.
Mitchell, S. D.
Watertown, S. D.
— Rapid City, S. D.
Marion, S. D.
... Sioux Falls, S. D.
Marion, S. D.
— Sioux Falls, S. D.
Beresford, S. D.
Yankton, S.D.
Sioux Falls, S. D.
Sioux City, Iowa
Sioux Falls, S. D.
PAPER
■"jr/:,"'‘///"‘ r- w
i 8
^ftl
,aMMW
^mmlF
(Editor's Note:
This address by Mr. Mossberg and those of Dr.
Johnson and Mr. Hoffman, which follow Mr. Moss-
berg’s address, were given at the Legal-Medical Meet-
ing held in Rapid City on September 10, 1966.
PROFESSIONAL LIABILITY —
ITS BASIS AND DEFENSE
W. A. Mossberg
MR. WILLIAM G. PORTER: Commencing
the program I would like to introduce to you Dr.
Marion R. Cosand, the medical chairman of our
joint medical-legal effort. Dr. Cosand.
DR. COSAND: Thank you, Mr. Porter, and
ladies and gentlemen. Today we are privileged
to have three excellent speakers with us. The
first is Mr. W. A. Mossberg. Mr. Mossberg has
had considerable experience in the insurance
field and this has culminated in his being the
regional claims superintendent of the St. Paul
Insurance Companies of St. Paul, Minnesota,
and at the present time he has charge of Illinois,
Michigan, Ohio and Oklahoma. He is graduated
from the University of Minnesota with an LL.B.
and BS.L, He was in private practice with
Meagher, Geer, Markham and Anderson, and he
will talk to us today regarding Professional
Liability — Its Basis and Defense, handling of
claims. Mr. Mossberg.
MR. MOSSBERG: Thank you, doctor, I’ve
been told that speakers at this sort of thing are
expected to have a joke or two. It’s kind of dif-
ficult for me — I only know two kinds — one,
too dirty to tell and the other just plain isn’t
funny, but I did run across something that made
me chuckle a little the other day. It concerns a
trucking company that was having quite some
trouble with their experience and so they de-
cided to hire a safety engineer, and this safety
engineer as a part of his routine was testing the
Reprinted with permission from the South Dakota
Bar Journal, January, 1967.
drivers. So he had the driver in and he said
“Now I want you to assume you’re on a moun-
tain road, you’re driving this sixteen axle rig,
you’ve been following a slow moving car and
you finally come to a straight stretch that’s on a
hill and it’s about a hundred feet down on both
sides and you pull out to pass. Now when you
get out in the other lane you see another sixteen
axle rig coming up the hill from the other
direction, what do you do?” Well, of course, he
said he’d slam on his brakes. The safety en-
gineer says “Fine, that’s what you’d do but let’s
assume the brakes don’t work, what do you do
then?” Well, he thought a while and he says
“I suppose I’d wake up George.” He says “Who’s
George?” “Well, he’s my relief driver, you
know. He’s back there in the sleeper.” “Well,
yeah, I suppose you would wake up George but
what good does that do?” He says “Well, I don’t
know, but George ain’t ever seen a real good
accident.”
I feel kind of out of place here, I’ve taken this
week off and I’ve been working at home laying
a stone wall. If there’s a stonecutters’ conven-
tion across the street I think I should go over
there.
A talk to a group such as this is rather dif-
ficult. You have to talk over some and under
the rest. Unfortunately between doctors and
lawyers there’s too little common ground.
Lawyers really don’t understand the problems
of the doctor. Doctors, ordinarily, have an amaz-
ing lack of understanding of legal principles.
I’m going to talk primarily to the doctor.
Some of the attorneys here may feel offended
because they feel I am talking in trite matters,
but I ask that you bear with me. Among various
things I’m not going to do, I am certainly not
here to put on some kind of a school to teach
attorneys how to win malpractice cases. I have
— 15 —
SOUTH DAKOTA
purposely stayed away from case citations. I’m
sure that the speakers to follow will fill in this
void quite ably.
One thing that continually comes to my atten-
tion is the failure of attorneys to get down to
basic propositions. We hire lawyers; we hire a
lot of them. We have a lot of them working for
us in the insurance company and it’s surprising
to see how often the real issues in a case are
ignored by these people who we would hope
understand what’s involved. I have a case right
now in which our insured left a disabled vehicle
on the highway and this vehicle was run into.
There were some very serious injuries. The
physical facts are quite clear; we know where
the vehicle was left, we know how the accident
occurred. Among other things, it’s alleged that
our man was quite drunk. I believe he was,
frankly. Our adjuster, who is a lawyer, spent
all of his time investigating this issue of in-
toxication. He followed the man’s activities —
he really did a fine job of investigating this and
he has put together a pretty good case to prove
that he was not drunk. Well, unfortunately, this
doesn’t do anything. This man has wasted his
time really; he’s been investigating an im-
material issue in this case. The controlling issue
here, of course, is where was this vehicle?
Whether the man was drunk or sober when he
left there really didn’t make any difference.
This, unfortunately, is the approach that’s taken
regularly by attorneys and doctors in consider-
ing professional liability.
Consider the automobile driver who crosses
the center line and hits an oncoming car. Ordin-
arily you would say that this man is liable to
the owner and occupants of the other car. Why?
Is it because he was on the wrong side of the
road? Well, yes, of course, that’s so. But this
isn’t the real legal issue. The plaintiff’s attorney
in this case proceeding just on this issue may
come up with nothing because there may be a
justification for being on the wrong side of the
road. Looking at the results, looking at the final
set of facts, is not the issue involved.
Consider the owner of property. Somebody
falls down and he’s hurt. Now is the owner
liable to this person who falls down and gets
hurt because he owns the property? Well, again,
yes, this is an element but this isn’t the con-
trolling issue.
I think it will profit the attorneys, as well as
the doctors, to go back to fundamentals and con-
sider where legal liability comes from. It comes
from a violation of duty. Every person has a
duty to every other person. This is basic law
but it’s so often overlooked. Sometimes this
duty is purely negative. The duty that you as
a property owner owe to, say a burglar who’s
trying to break into your house, is strictly a
negative duty.
The motorist has duties to all other persons
using the highways. He has a duty to maintain
control of his vehicle, maintain the vehicle in
a safe condition, generally act as a reasonable
and prudent person, but, this doesn’t mean that
anyone who is injured by this motorist is en-
titled to recover. It means that if this man has
violated his duties then legal liability attaches.
This motorist that’s on the wrong side of the
highway, if he is out there because he was hit
by someone else and pushed onto the wrong side
of the road, doesn’t owe the oncoming car. Now
time and again I see this type of thinking, not
only by doctors, if you please, but lawyers as
well. They look for the result and they say
that because of the result there’s liability. Well,
it just isn’t so.
A very common misconception among lay
people is this business of who hits who in a car
accident. Suppose you have a multiple car
rear-ender. Somebody stops because of an ob-
struction and the next car either stops or comes
close to stopping, somebody down the chain
finally ends up hitting the car and you have your
chain reaction of bump, bump, bump. So often
the only question that anybody asks is “Who hit
me?” Then, he owes me because he hit me, with-
out considering what this man either did or
failed to do to supply the basis of liability.
In the fall-down case on property, this owner
of property may have leased the property away
and as lawyers you all know that in that ar-
rangement the tenant takes the property as he
finds it. If this claimant happens to be the tenant
and the condition that caused him to fall pre-
existed the lease, there is not liability. The ques-
tion isn’t who owns the property, the question is
who did something wrong. In professional lia-
bility it isn’t the bad result, it isn’t the un-
fortunate occurrence that supplies the basis for
legal liability. You’d have to go back as in the
auto case or the fall-down case and say “Who
did or didn’t do what they were supposed to
do?”
In the case of the claims against doctors, you
consider the duty that the doctor has to the
patient. Well, what is it? First of all he has to
be qualified for the position that he purports to
hold. He has to qualify under the basic sciences
law if you have one. He has to have the educa-
tion, the training, the skill that a person in his
— 16
JULY 1967
profession ought to have. He has to use those
skills and that learning according to the stand-
ards of the community in which he practices.
He has to observe the personal rights of the pa-
tient. For instance, assault claims, civil rights
claims, that sort of thing. He has to perform as
he has contracted to perform. Of course he has
Ito observe all the laws that are applicable to
every other person outside of his professional
duties. For instance, he must not conspire to de-
prive someone of his property or rights.
Skill and learning is fairly easy. We ordin-
arily don’t find someone professing to be a doc-
tor who is not. If the man has graduated from
medical school, if he is licensed to practice in
the state, generally speaking, the law will recog-
nize that he has the skill and learning that is
required of him.
Now using that skill and learning in con-
formance with the community standard is quite
another thing. What is the community stand-
ard? This is a factual question to be decided in
each individual case and it is a question that has
to be proved by expert testimony. Unfortun-
ately, when attorneys have a professional lia-
bility claim against a doctor and it dawns on
them that they do need expert testimony they
go out shopping for the wrong answers. They
call up a doctor and they say “Doctor, what do
you think about this case?” Well, what he
thinks about this case doesn’t make any dif-
ference. That’s not the test. In determining
whether the doctor defendant has conformed to
the community standard, the opinion of another
doctor as to, “Would I have done the same
thing” is absolutely out of point. It’s im-
material.
Community standards vary. Lawyers fre-
quently would like to believe that there are
such things as universal standards so that they
can import a doctor from here, there or any-
where to testify concerning what is the standard
in this local community. It might be nice for
some if that were the case, but it is not. There
are many areas in this country yet today where
kitchen table surgery is the custom. You can’t
accuse this doctor who is in such an area be-
cause he didn’t have the cardiac arrest tray
handy when the next door neighbor came in and
started dropping ether. This applies as well to
all other professions. You are judged by the
standards of the community in which you prac-
tice, and the attorney who has a case either for
or against a doctor in this situation must direct
his thinking to that community and not say
“Well they do it different at Childrens Hospital
in Boston.” Maybe they do.
Mistakes are made. I’m sure there is no one
here who either hasn’t made them or knows of
them. Doctors are human beings. They are not
perfect. Is a mistake grounds for claiming legal
liability? The answer is no. When a patient
comes to the doctor, the human frailties of that
doctor are a risk that the patient must assume.
We have successfully defended in our company
many, many claims involving obvious mistakes.
The doctor explores and thinks he has identified
the cystic duct and it turns out to be the com-
mon duct but he ties and cuts it. He is doing
a hysterectomy and he thinks he’s tying off a
uterine artery and it turns out to be a ureter.
These are clearly mistakes of course, but the
committing of this mistake is not of itself proof
of legal liability on the part of the doctor and
the attorney who takes a case thinking that he
is going to win just by proving this has got a
real shock coming. Certainly, a mistake can be
the basis of liability but, this is at the tail end
not at the beginning. The question is, “Did this
doctor while performing this surgery use his
skill and learning and did he conform to com-
munity standards?” Now if he did and still made
a mistake, it’s unfortunate but that’s the end of
it. If he makes a mistake because he failed to
use his skill or conform to standards that’s quite
another matter. The point I’m trying to make is
that the mistake isn’t the test. The test is the
doctor’s compliance with the standards of the
community and his application of his skill and
learning according to his ability.
Certain cases have been decided by our courts
to be so clear as to require no expert proof. I
suppose the leading case is the foreign body
case. That is, if the doctor leaves a sponge or a
clamp or what have you, and some of these get
pretty weird. I know of one particular case in-
volving a fractured femur. The man had con-
siderable trouble for some time after this was
worked on and he was plumped and probed,
etc., and finally they decided to take an x-ray.
The man came in and had his x-ray and then
he went home and a couple days later he called
up the doctor and said “What about that x-ray?”
The doctor said “Well, you got to come back and
have another taken and this time when you have
the x-ray taken, take your pants off, will you.”
He says “What do you mean?” “Well I can’t tell
anything, with that pair of pliers you’ve got in
your pocket.” Well, the man didn’t have his
pants on. It’s kind of hard to imagine how a
piece of machinery about this long can be left,
17 —
SOUTH DAKOTA
but it was, and that’s true. A recent case, (when
I say recent, it is about four years ago now) was
a suit against the Mayo Clinic. The operative
procedure was a parathyroidectomy and this in-
volves a pretty small incision; it is fairly deep
but there just isn’t a very big hole made. Some-
body left a sponge in that hole. Some of these
things are hard to believe and generally speak-
ing in that type of case our law will not require
that you go beyond the fact itself. That is, that
there is a foreign body left. At that point the
burden of proof shifts to the defendant to ex-
plain his way out of it if he can. Here, if you are
the plaintiff’s attorney suing the doctor on a
foreign body case, if you rely only on that fact
and inquire no further, watch out, because you
may get a real shock. These foreign body cases
are not absolutely indefensible. There are many
situations in which this foreign body is justified.
Consider the thoracic surgery, this is a mess —
I’m not telling you doctors anything, but for you
lawyers this is a really gory procedure. You
have blood running all over. You have sponges
by the pail full. Now during this procedure if
the anesthesiologist looks up and says “Doc, I
think you better close up and get out of here,
I think this guy’s going down,” you don’t take
an hour off and start counting sponges. You
close up and get out and if in this case a sponge
is lost, it is justified. We have tried many cases
of that sort and successfully defended them. So
again, don’t stop with the result. Really this is
the whole message I have in professional lia-
bility, the result is not the test. There are these
mechanical problems but they are rare really.
In most of your unfortunate result cases there
has been judgment involved. Now there may
be legal liability for faulty judgment, but it is
not on the basis of faulty judgment. It must be
on the basis of the failure of the professional
man to do what is routinely called for in form-
ing the judgment. The doctor who makes a diag-
nosis is not liable to his patient because he is
wrong in the diagnosis. If he has failed to make
the tests that are routinely employed in that
community in order to make the diagnosis, then
he may be in trouble.
Another area is the matter of informed con-
sent. Unfortunately there is an awful lot of
misunderstanding about this, not only among
the practitioners but among the courts as well;
and I suppose in Minnesota we’re as guilty as
anyone. Our court kind of led the way in a case
that I had a part in preparing. All of you doc-
tors certainly know Doc Foley in the Twin
Cities. For the benefit of the attorneys here,
this man was a very famous urologist. He had
an old patient, Jelmer, and Jelmer had some
trouble. He had a little cancer in the prostate
and Doc Foley said “Well, Jelmer, we’re going
to have to whack that out” and Jelmer said
“yah.” So he operated on him and as is routinely
done in this procedure there was a prophylactic
vasectomy done. Now this is medically neces-
sary. It is just like a cancer of the breast case.
When the doctor operates, he doesn’t just whack
out a little piece of meat, he goes way up under
the arm and if there is any indication, anything
calling for it, he’ll go way on up, he’ll take out
the glands, the lymph glands under the arm,
perhaps go way down the arm. Well the same
thing with this problem of Ole Jelmer. If there
is cancer in the prostate and if you want to cure
the patient you better get all the associated
tissue into which the cancer may go. Well, Jel-
mer woke up and somewhere along the line it
dawned on him that there had been a vasectomy
done and he got awful sore about this and mama
got sore about this too. Jelmer was approaching
eighty and so he got himself a lawyer and he
sued old Doc Foley. He said “Doc, I told you
to whack out that cancer, I didn’t tell you to go
monkeying around with anything else.” Then
Jelmer got on the stand and he told about all
the fun he used to have and now he can’t no
more and mama did too. Well, we got a directed
verdict and Jelmer wasn’t satisfied with that
so he went up to the Minnesota Supreme Court
and the Supreme Court says: “Hey, Doc Foley,
you didn’t tell him what you were going to do.
You told him he was going to have an operation
on the prostate but you didn’t tell him you were
going to do anything else. Now this man is en-
titled to know what’s going to be done to him
and you better tell him.” So, it was sent back
for new trial. Now, this doesn’t appear in the
case books of course, all you read there is the
decision of the Supreme Court on that first
trial, but the fact is that we did try it a sec-
ond time and the jury went out at about a quar-
ter to twelve, took that last fifteen minutes of
the morning to elect a foreman went and had a
free lunch on the county and when they came
back at one o’clock they spent another five
minutes and came in with a defense verdict.
The patient is entitled to know what’s going
to be done to him. Now the basic law is this.
Everyone of us has a duty to everyone else not
to touch him; not to physically interfere with
his person. To get around this you must find
consent. When you walk down the sidewalk you
impliedly consent for the jostling that you're
— 18 —
JULY 1967
going to get as a routine matter. All of us, as
we come out of this room, impliedly consent
to the contact that there may be between us as
we go through the door. But there must be con-
sent to any touching of the body and if there is
not, there is an illegal assault. Now this consent
must be with knowledge of what’s involved and
this is really what this informed consent is all
about. It is a qualification of the law of assault.
I don’t know what the standard is here locally.
I presume it is about the same as most every-
where else. If you’re in there on an exploratory
laporotomy you very likely will do a prophy-
lactic appendectomy. Well, if you consider that
this is necessary you better tell your patient
what you’re going to do before you do it. Keep
in mind, granted the appendix is no good to
him, this man is entitled to his appendix and
you can’t take it without telling him. It’s point-
less to go into great detail about the various
legal problems involved. I would say this to the
doctor, be a good doctor, tell your patient what
he is entitled to know but do this consistent
with good medicine.
I speak now as a representative of the insur-
ance industry. We’re not going to be particularly
concerned about a lawsuit on informed consent
where medically it would have been inadvisable
to discuss the matter. How much elective sur-
gery would there be if you went into great de-
tail with your patient concerning all of the risks
and all of the things that you are going to do.
In Doc Foley’s case, after this case was con-
ducted, he wrote a letter to the Chief Justice of
the Supreme Court and told him what he had
done by this decision. He said “How much op-
erating are we going to do?” He said “I have to
tell this fellow ‘Charlie you have cancer and I
think you’re probably going to die but I think
I can save you. In order to do this I am going
to have to operate on you. Now you know what
that means. First of all you’re going to have
to go to the hospital and you know those damn
hospitals. Somebody’s liable to let you fall down
an elevator shaft. Well, assuming you get by
that and you get into your bed safely, this nurse
is going to come in and she’s going to give you
some medicine the night before to kind of put
you at ease. Well, just like as not she’s going to
make a mistake and give you the wrong thing
that might kill you but, if you survive the night
then come next morning somebody is going to
come in since we have to shave you. Well,
they’re going to go scratching around with that
razor and they’ll probably nick you and you
know all this staph infection in the hospital;
you’ll probably die from that; but, if you live
long enough to get to the operating room then
we’re going to have to put you to sleep and you
know there’s a certain percentage of people who
just plain die from the anesthetic!” Well, it goes
on and on for several pages. Legally it’s correct.
Legally if you were to be safe you would have
to go through all this rigmarole. But this is
nonsense. This is a risk that we as insurers very
gladly accept. Be a good doctor. Be a doctor
first. Don’t worry about the law. Certainly,
under such circumstances there would be no
elective surgery at all, and there would be very
little emergency. What this informed consent
does really is change the nature and the quan-
tity of proof that is required in a malpractice
claim. In proving care, skill, etc. your test is
the standard of the community and to prove
this we require expert testimony. If there is a
violation of this man’s personal rights, if some-
thing has been cut out of him that he is entitled
to keep, if he hasn’t been told the risks of the
procedure, then you are in an area where you do
not need expert testimony. You have a fact
question that the jury can decide on lay tes-
timony and the serious problem for the doctor
of course in this situation is that something may
go wrong. For instance, the prophylactic appen-
dectomy. So you take his appendix out, so what,
what’s his damage? Nothing! But unfortunately
sometimes things go wrong. I recall a case quite
recently involving just this procedure. The tie
came loose on the stump and this man had real
problems. There was fecal material leaking
out into the abdominal cavity. He had a real
fine infection going. Now technically there
wasn’t anything really wrong. What the doctor
had done would have been defensible had it not
been for the fact that he did something that the
patient didn’t know about. If he had been in
there for an appendectomy and if this had hap-
pened we could have successfully defended him
because he did comply with the community
standards. He put the tie on, he tied it properly.
It was just one of those unfortunate accidents
that happen. But, because he had gone in there
without the consent of the patient, without tell-
ing him what he proposed to do, the issue of
skill and care was not involved. It was only a
question of assault and the damages of course
follow right along behind. I would just say this.
Assault and informed consent is nothing mag-
ical. Reading the cases you may think it is but
it’s just a qualification of the law of assault.
You avoid an accusation of assault by informing
the person that you are going to touch him, and
19 —
SOUTH DAKOTA
getting his consent to do it and to get consent he
has to know substantially what it is that he’s
consenting to.
Unfortunately, the law of contracts gets into
the doctor’s field all too often. I don’t know why
this is but for some reason or other derma-
tologists seem to be the prime target. I suppose
because very often they are working in cosmetic
surgery which is an elective sort of thing that
nobody really needs. They think they need it,
they want it, but there is no serious health
hazard involved. The doctor insists on telling
his patient that he is going to produce a 50%
improvement for him or 100%. Now this is a
contract and you are outside the field of neg-
ligence or care and skill of the community. It
is a plain out and out contract and I would say
to you doctors, don’t do it. If your patient says
“How am I going to come out?” scratch your
head and say “Well most people . . .” or some-
thing of that sort but for heaven sakes don’t
guarantee a result. You can’t do it. And, if you
do and if it goes sour you are stuck on a con-
tractual basis.
Doctors are subject to a lot of unusual ex-
posures. Most doctors have some hospital staff
position or medical association position which
may be the source of a claim against them.
Activities of this sort are certainly commend-
able. We as insurers again have no hesitation
about encouraging these things. We willingly
accept the defense of the claims that we get as
a result of these activities. You should police
your profession. You should clean out the un-
desirable. Unfortunately today when you do
that you’re probably going to get sued. We have
suits pending all around the country against the
staff committees of hospitals. Some doctor is
kicked off the staff because the Tissue Commit-
tee reports that most of his surgery was un-
necessary and now he’s mad because he’s off
the staff and he sues the members of the Tissue
Committee. The hospital staff elect not to allow
chiropractors or osteopaths to practice in the
hospital and they get sued on a claim of a con-
spiracy. Of course this doesn’t stop with the
doctors. This goes into all professions. Realtors
get these claims against them. They belong to a
multiple listing exchange. Some realtor has
made a habit of inviting lady friends to houses
that he’s allegedly showing and gets kicked off
the multiple listing exchange because of it and
now he sues the realtors in the town alleging
conspiracy. Don’t worry much about it. Be a
good doctor, be a good lawyer. Practice your
profession and let these problems fall where
they may. There are problems with publica-
tions. Every so often a doctor will get sued be-
cause he wrote a paper without getting a model
release from somebody that had a picture or a
waiver from a patient whose case is described.
This is a theoretical area of legal liability but,
I would say to you, as a representative of the
insurance industry, don’t worry about it. Go
ahead and practice your profession.
Attorneys are really subject to the same law.
Again it’s a standard of the community. Most of
the claims against attorneys are on mechanical
problems. The statute of limitations has been
let run; there’s been an error in filing something
that should have been filed with the registrar
of titles instead of the Register of Deeds office.
These are about like foreign body cases to the
doctor. They at least start out with the appear-
ance of liability. There isn’t an awful lot of ac-
tivity in lawyers professional liability at this
time in this area. When you go east there is.
Hopefully it won’t get out here.
As to what we do with a claim in the insur-
ance company. Well of course its like any other
claim. We have our internal office routines that
have to be gone through. We have to check the
coverage to see to it that we do insure the man,
that the limits of the policy are adequate, etc.
This is the same routine that we go through
whether it is an automobile case, fall-down or
what have you. The handling, and I can speak
generally for the industry, although there may
be a company here or there that will not follow
this pattern, is quite different. Our handling of
a professional liability claim is keyed to the law
which is somewhat different than that in an
automobile case. In the automobile case of
course you go out and you contact everybody
you can find and you take statements and you
negotiate, etc. Not so in the professional lia-
bility case. When we get the report most com-
panies will make a fairly careful inquiry of
their own insured. In most cases we will not
go beyond that. I say this to both the doctors
and the lawyers: If you have a problem, if there
is a potential claim against you, for heaven
sakes report it to your carrier. Don’t sit back
because you’re afraid the insurer is going to
go out and stir up trouble. We will investigate
these things only to the point necessary to ade-
quately defend you. In the case of the doctor,
we will rarely contact the patient. There's no
point to it. In the surgical case, what can we
find out from the patient who was under an
anesthetic. He can’t tell us anything. We will
not go out and create a public issue of these
— 20 —
JULY 1967
claims. Trust our discretion. We’re there to
serve you. We’re not going to create a problem
where there is none. Tell us about it; make use
of your coverage. We can only help you, we can
only perform according to our contract if you
report these things to us and give us a chance.
Routinely in professional liability claims the
plaintiff’s attorney’s typewriter gets stuck. It
seems that there is some tape or something
stuck over the zeros. You hardly ever see a
suit for $5,000 or something of that sort; it’s for
$500,000 or a million and a half. Ordinarily you
will not be insured for that kind of money so
routinely you will get a letter from your insurer
telling you or reminding you that you have been
sued for more than your limits and that you
may, if you choose, retain your own attorney.
I say now to the attorney who is hired by the
doctor as his personal representative, do what
you have to, you’re the lawyer, you know the
law, you know what you have to do but think
a little bit, and before you advise the doctor
contrary to a position that the insurer is taking,
make reasonably sure that you know more
about it than we do. Malpractice cases are not
common. Most attorneys are not expert in this
field and I assure you that these matters are not
handled like the fall-down or the auto accidents.
If you are called upon in a case of this sort,
scratch your head a bit. Do what you have to
but don’t just off the cuff advise the doctor to
take a position adverse to what his carrier
would like to take.
I would say this to the attorneys who may
have a plaintiff’s case. Be responsible, please!
I’m not talking law now, I’m talking common
sense and humanity. Feel responsible. You’re
dealing in a professional field. This isn’t like
the auto case. There’s no particular stigma at-
tached to being a defendant in an auto case.
(Actually, it doesn’t hurt a professional man
particularly either. I don’t know of anybody
who has lost any income because he got sued.
I don’t know how frequent these suits are here
but I do know in St. Paul and then going east,
that if I walk into the doctors’ room in a hos-
pital everybody there knows me). But the pro-
fessional man himself worries a great deal about
this and there are people that will attach an im-
proper association to a claim of this sort. So
don’t do these things just for fun. I suppose it’s
fair to say that any auto or fall down case that
you might have is worth something. I keep tell-
ing the claim men that work for me that it isn’t
so, but the fact is that if you start a non-meritor-
ious case, ordinarily you can get out with at least
some savings of face. Again I can’t speak for the
entire industry. There may be companies, as a
matter of fact there are companies, who haven’t
learned their lesson yet and who will attach a
nuisance value to a professional liability claim.
We don’t. Most of the major professional lia-
bility writers do not. There just plain is no such
thing as a nuisance professional claim. If we
don’t owe it, we aren’t going to pay it. We’re
not going to give you five cents, so if you start
a malpractice claim you better figure that
you’re going to trial. If you have a winner, most
of us would like very much to dispose of that
claim. We will try to put a fair figure on it. Of
course that’s a pretty loose term and certainly
there are going to be disagreements but, try to
work it out. Don’t just haul off and sue without
at least exploring settlement possibilities. These
cases, to the insurance company, are either
black or white. If they are cases of liability we
would like to dispose of them as quickly as
possible and to do so we don’t try to quibble.
Admittedly we may not come up with the same
evaluation that you do but we would like to get
rid of them. On the other hand, if we feel that
we can defend these claims we are not going to
pay you anything, so when you have a client
who thinks he has a professional liability claim
look it over and think it over and act respon-
sibly. You’re not doing yourself any favor when
you sue a loser, you know. You’re much better
off to tell that client “Charlie you just plain
haven’t got anything here, why don’t you forget
it.” I know that this doesn’t go well but it’s
better to do that than to explain to old Charlie
after the case is over why he has to scratch up
the cost money.
Some practical comments so far as insurance
is concerned. Don’t rely on institutional cov-
erage. Now this doesn’t have too much appli-
cation to the lawyers, but it does to the doctors.
If you’re working in a hospital don’t assume
that you’re covered by the hospital policy. You
may be, but don’t assume it, check on it. To
the doctors and lawyers; if you’re in a firm and
you leave, don’t forget your insurance. Check
on it, see how you are insured. See whether this
coverage follows you when you go on your own
or into a new firm. There are an awful lot of
unnecessary problems arising out of this failure
to pay attention to your insurance. I don’t know
why this is but it’s an odd thing that the dentist,
for instance, that moves he makes sure he’s got
the direct loss coverage on the chair and on the
tools, etc. but it never dawns on him to check
on the liability coverage. I suppose this is true
21
SOUTH DAKOTA
generally. People are much more concerned
about being sure that the fire insurance on the
house is paid than they are with the liability
insurance or the liability coverage on the auto.
I would remind you to pay attention to this and
especially doctor, don’t rely on an institution to
be protecting you. Th 
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